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COPYRIGHT DEPOSIT. 



Post-mortem Pathology 



A MANUAL OF POST-MORTEM EXAMINATIONS 

AND THE INTERPRETATIONS TO BE 

DRAWN THEREFROM 



A PRACTICAL TREATISE FOR STUDENTS AND PRACTITIONERS 



BY 

HENRY W. CATTELL, A.M., M.D. 

PATHOLOGIST TO THE PHILADELPHIA HOSPITAL AND THE WEST PHILADELPHIA HOSPITAL FOR WOMEN, 
AND SOMETIME DIRECTOR OF THE JOSEPHINE M. AYER CLINICAL LABORATORY OF THE PENNSYL- 
VANIA HOSPITAL ; SENIOR CORONER'S PHYSICIAN OF PHILADELPHIA ; PATHOLOGIST TO THE 
PRESBYTERIAN HOSPITAL ; PROSECTOR OF THE AMERICAN ANTHROPOMETRIC SOCIETY ; 
DEMONSTRATOR OF MORBID ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. 



WITH 162 ILLUSTRATIONS 



" Rotto dal mento insin dove si trulla. ' 
Tra le gambe pendevan le minugia; 

La corata pareva, e iltristo sacco 
Che merda fa di quel che si trangugia.' 



-Dante 



PHILADELPHIA AND LONDON 

J. B. LIPPINCOTT COMPANY 

1903 



<b 



THE LIBRARY OF 
CONGRESS, 



Two Copies Received 


JUN 5 


1903 


; Copyright 


Entry 


lyu^/Ji/ \T- 


1 C3 
XXc No 


CLASS cu 


I 1 i 8 


/ 


COPY 


B. 



Copyright, 1903 
By J. B. LippiNCOTT Company 






PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U.S.A. 



TO THE MEMORY OF 
MY FRIEND 

DR. THOMAS S. KIRKBRIDE, JR. 

WHOSE EARLY DEATH WAS A 
SAD LOSS TO 

AMERICAN PATHOLOGY 



PREFACE 

¥¥ 

This book has been written for those who ought to make autopsies 
but do not and for those of whom such investigations are required, as 
medical students, hospital interns, and coroner's physicians. While 
it would seem to be quite needless to urge upon a practitioner the 
importance of performing post-mortem examinations, it is a fact that 
extremely few are made outside of hospitals, and even there necrop- 
sies are usually conducted by the untrained resident or the substitute of 
the pathologist. It cannot be questioned, however, that the physician 
who improves his opportunities for pathological study on the cadaver 
will be a better diagnostician and safer therapist, will have a more 
enduring reputation, and will receive a greater pecuniary return than 
he who neglects such means of investigating morbid processes. 

While the author has mainly relied upon his personal experiences 
in the preparation of the subject-matter of this manual, he has freely 
used classifications and material derived from Orth's Pathologisch- 
Anatomische Diagnostik, Osler's Practice of Medicine, Nauwerck's 
Sections-Technik, and other publications mentioned in the foot-notes 
and in the text. He is, therefore, much indebted to these authorities, 
as well as to Dr. George Robinson and Mr. Louis Schmidt for 
most of the drawings, all of which were prepared under the writer's 
direction, to his friends and former students Drs. William S. Wads- 
worth, Mary E. Lapham, E. D. Burkhard, and Edward Lodholz 
for suggestions in the preparation of the book, and to that excellent 
proof-reader Mr. T. Grow Taylor for seeing the work through the 
press. 

HENRY W. CATTELL. 

3709 Spruce Street, Philadelphia, March 31, 1903. 



CONTENTS 



CHAPTER PAGE 

I. General Considerations i 

II. Post-mortem Records and Note-taking 14 

III. Post-mortem Instruments and How to use them 24 

IV. The Care of the Hands and the Treatment of Post-mortem 

Wounds 40 

V. Enamination of the Exterior of the Body 46 

VI. Technic of Exposing the Abdominal Cavity and the Superfi- 
cial Examination of the Parts contained therein 54 

VII. Technic of Exposing the Thoracic Cavity and the Examination 

of the Parts contained therein 64 

VIII. Lesions of the Heart, Blood, and Blood-vessels 76 

IX. Examination of the Pleura, Lungs, and Upper Air-passages .... 93 

X. Diseases of the Lungs, Pleurae, and Accessory Parts 97 

XL Critical Examination of the Organs of the Abdominal Cavity ... 112 
XII. Diseases of the Kidney 145 

XIII. Diseases of the Bladder, Fallopian Tubes, Ovaries, Uterus. 

Vagina, and Testicles 151 

XIV. Diseases of the Liver and Gall-ducts 157 

XV. Examination of the Skull and Brain 164 

XVI. The Spinal Canal and Cord 180 

XVII. Diseases of the Brain and Cord 183 

XVIII. Examination of the Nasopharynx, Eyes, and Ears 193 

XIX. Post-mortem Examinations of the New-born 197 

XX. Restricted Post-mortem Examinations 200 

XXL Restoration and Preservation of the Body 203 

XXII. Diseases due to Micro-organisms, Parasites, and H^matozoa .... 209 

XXIII. The Preservation of Tissues for Macroscopic and Microscopic 

Purposes 244 

XXIV. Bacteriological Investigations 263 

XXV. Weights and Measures 267 

XXVI. Comparative Postmortems 281 

XXVII. Medicolegal Suggestions 305 

XXVIII. The Prussian Regulations for the Performance of Autopsies in 

Medicolegal Cases 336 

XXIX. Usual Causes of Death ; their Nomenclature, Complications, 

and Synonyms 348 

vii 



LIST OF ILLUSTRATIONS 

FIG. PAGE 

i. Post-mortem room of Ayer Clinical Laboratory, Pennsylvania Hospital . . 8 

2. Plans for post-mortem table 8 

3 and 4. Refrigerator box with scales arranged to weigh body while in it ... . 9 

5 and 6. Plans for refrigerator box for storage of bodies 10 

7 and 8. Plan for a combination electric, gas, and water fixture above post- 
mortem table 11 

9. Combination electric, gas, and water fixture for post-mortem table 12 

10. . Section- or cartilage-knife 24 

1 1. Cartilage-knife with projection on back 25 

12. Post-mortem knife with faulty point and improper belly 25 

13. Brain-knife marked as a measuring rule 25 

14. Bread-knife for incising large organs 25 

15. Valentine's knife 26 

16. Pick's myelotome 26 

17. Saw for post-mortem work 26 

18. Butcher's saw for post-mortem work 27 

19. Hey's saw 27 

20. Metacarpal saw 27 

21. Luer's double rhachiotome 27 

22. Cryer's electrical surgical engine 28 

23. Strong scissors with short blades 29 

24. Scissors with one dull point and with bent handles 29 

25. Proper form of enterotome 30 

26. Improper form of enterotome 30 

27. Proper form of costotome 30 

28. Improper form of costotome 31 

29. Steel hammer with proper handle 31 

30. Steel side chisel 32 

31. Curved chisel 32 

32. Brunetti's curved spinal chisel 32 

33. Satterthwaite's calvarium clamp 33 

34. Iron clamp for attachment to skull before removing brain 34 

35. Bigelow clamp 34 

36. Folding iron head-rest 34 

37. Cornell folding clamp 34 

38. Cones for measuring orifices 34 

39. Glass balls for measuring orifices 35 

40. Hemp twine ready for use 37 

41. Formad's pocket-case for post-mortem instruments 38 

ix 



x LIST OF ILLUSTRATIONS ' * 

FIG. PAGE 

42. Method of holding cartilage-knife 35 

43, 44, and 45. Scheme showing various forms of incisions for examining 

thorax and abdomen 54 

46 and 47. Initial incision over sternum (vertical and lateral views) 54 

48 and 49. Right thoracic flap made in opening body (vertical and lateral 

views) 54 

50. Opening of abdominal cavity 55 

51. Method of severing costal cartilages 55 

52. Method of separating sternoclavicular attachment 64 

53. Incision of first left rib 64 

54. Incising first rib and sternoclavicular articulation with costotome 65 

55. Severing diaphragmatic attachments of sternum 65 

56 and 57. Final steps in removal of sternum 65 

58. Breastplate after its removal from the body 70 

59. Method of covering ribs with skin-flap for protection of operator's hands, 

and methods of enlarging abdominal opening 70 

60. Opening of pericardium 71 

61. Primary incisions for opening heart 71 

62. Secondary incisions for opening heart 71 

63. Completed incisions for opening heart 71 

64. Opening of right auricle 72 

65. Opening of left ventricle 72 

66. Removal of heart from body 72 

67. Incision of pulmonary veins 72 

68. Examination of right ventricle and of pulmonary artery 73 

69. Examination of left auricle and ventricle 73 

70. Reconstruction of heart after completed incisions 72, 

71. Opening of lung 94 

72. Lung laid open for minute inspection 94 

72,. Minute examination of pulmonary vein 95 

74. Examination of bronchi 95 

75. Method of removing tongue, tonsils, oesophagus, bronchus, etc., in a single 

piece 96 

76. Method of examining oesophagus 96 

77. Examination of organs of neck 97 

78. Method of opening trachea 97 

79. Examination of trachea and vocal cords 97 

80. Method of removing intestines 114 

81. Method of passing string through mesentery previous to tying the same . . 116 

82. Bucket method of opening and cleansing intestines 116 

83. Removal of small intestines 116 

84. Opening of small intestine after its removal 116 

85. Incision of the kidney with its ureter still attached 116 

86 and 87. Method of opening kidney 127 

88. Relations of pancreas, kidney, ureter, adrenal, and solar plexus 131 

89. Preparation of body for post-mortem examination of rectovaginal region. . 117 
90 to 97. Removal of bladder, rectum, uterus, and its adnexa en masse and 

restoration of the parts 117 

98. Lines for opening uterus I3 2 

99. Uterus and adnexa after opening 132 



LIST OF ILLUSTRATIONS xi 

FIG. PAGE 

ioo, ioi, and 102. Examination of testicles, epididymis, spermatic cord, etc., 

without disfigurement 136 

103. Examination of seminal vesicles 136 

104. Removal of liver 136 

105. Examination of biliary ducts and vessels 137 

106. Method of incising liver 137 

107. Examination of gall-bladder and hepatic and pancreatic ducts 138 

108. Examination of stomach 137 

109. Preliminary skin incision for opening skull 164 

no. Parting of hair so as to prevent its injury in incising scalp 164 

in and 112. Angular method of sawing skullcap 164 

113. Method of breaking up inner table of skull 165 

1 14. Method of drawing off skullcap 165 

115. Appearance of dura mater after removal of calvarium 165 

116. Appearance of brain after removal of dura 172 

117. Removal of brain from skull 172 

118. Dissection of brain ; commencement of initial incision 173 

1 19. End of initial incision 173 

120. Exposure of central portions of brain 173 

121. Central portion of brain, with cerebellum,, pons Varolii, and medulla 

oblongata still attached 173 

122. Segmented brain 174 

123. Separation of cerebellar lobes from pons Varolii and medulla oblongata . . 174 

124. Method of sectioning cerebellum 174 

125. The whole brain after it has been sectioned 174 

126. Sectioning of brain without separation of individual parts 175 

127. Basal ganglia, with cerebellum, pons Varolii, and medulla oblongata still 

attached 174 

128. Sectioning the brain according to Flechsig, Brissaud, and Dejerine 175 

129. Dejerine's incisions of brain in cortical lesions 175 

130. Lines for removing spinal cord and brain through a small triagular 

occipital incision 180 

131. Position of body in removal of spinal cord 180 

132. Removal of spinal cord ; primary incisions 180 

T-33- Completion of sawing 181 

134. Opening of spinal canal 181 

135. Severance of atlas and axis 181 

136. Final steps in removal of spinal cord 181 

137. Methods of examining nasopharynx, eyes, and ears 194 

138 and 139. Harke's method of examining nasopharynx 194 

140. Examination of umbilical vessels 195 

141. Examination of ductus arteriosus 195 

142. Removal of spinal cord of a child 195 

143 and 144. Method of examining for syphilitic osteochondritis of the femur 202 

145 and 146. Method of examining nasal cavities, antrum of Highmore, etc. . . 202 

147 and 148. Method of sewing up body 203 

149. Slee's method of fixing skullcap 203 

150. Author's method of holding skullcap in place 203 

151 and 152. Refrigerator plant for preservation of bodies, University of Penn- 
sylvania 208 



x ii LIST OF ILLUSTRATIONS 

FIG. PAGE 

153. Guinea-pig upon which a post-mortem examination has been made in a 

Ravenel pan 209 

154. Post-mortem examination of animals ; equine viscera 285 

155. Further dissection of Fig. 154 286 

156. Further dissection of Fig. 155 288 

157. Lines for opening cephalic cavities of a horse 295 

158. Lines for opening cranial cavity of a horse 295 

159. Lines for exposing cranial and nasal cavities in ruminants 298 

160. Appearances of cranial cavity of a cow 298 

161. Post-mortem examination of dog 300 

162. Exposure of oral and pharyngeal cavities in a dog 301 



POST-MORTEM EXAMINATIONS 

CHAPTER I 

GENERAL CONSIDERATIONS 

Postmortem, autopsy, and necropsy 1 are synonymous terms ap- 
plied to the systematic exposure and critical examination of the ca- 
daver with the object of determining the cause of death or of studying 
morbid anatomy in any of its various aspects. In no other department 
of medical science are the faculties of observation and discrimination 
more vigorously called into play, and in none other are sound knowl- 
edge and accurate work so indispensable. 

As the purpose of a post-mortem examination is the acquisition 
of exact data to be employed either for the promotion of the ends 
of justice or for scientific use, the information acquired should be 
obtained in a regular and systematic manner. This is especially im- 
portant in medicolegal cases, which frequently involve not only the 
reputation and liberty, but even the life of a human being. If the 
examination is conducted in a perfunctory or desultory way, some 
detail of the greatest importance may be overlooked, or the informa- 
tion obtained may be so undigested as to be practically valueless for 
statistical or demonstrative purposes. 

Relying upon one's memory for records is a treacherous device, 
and appearances which seem to be of no importance while the organ 
is before you are often of value to others who for various reasons 
may be called upon to read the protocol of the autopsy, but who have 
not had the opportunity of examining the parts in which they are 
interested. 



1 Other synonyms are necroscopy, mortopsy, obduction, section, sectio, and post 
(colloquial). German, Autopsie, Section, Selbstsehen, Leichenoffnung, Obduction, 
Necropsie, and Nekroscopie ; French, autopsie, obduction, necropsie, and necro- 
scopie; Italian, autopsia, autossia; Spanish, autopsia; Greek, aurora ; Latin, autopsia, 
necropsia, necropsis, necroscopia, sectio cadaveris, and sectio anatomica. The Ger- 
man word Obduction is correctly applied only to a medicolegal postmortem. 



2 POST-MORTEM EXAMINATIONS 

All notes should, therefore, be dictated while the autopsy is in 
progress, and should consist exclusively of descriptions of the con- 
ditions then and there observed. Names of diseases should be omitted 
in the notes themselves, but are to be inserted under the heading of 
" Pathological Diagnoses" at the head of the report. The record of 
morbid changes present ought to be full, clear, and exact, so that from 
it alone the pathological lesions can be made out by another pathologist 
as well as by the one who performed the necropsy. One well-worded 
description of an autopsy dictated to a reliable amanuensis during the 
progress of the work is of much more value than scores written from 
memory after their completion. Drawings, photographs, skiagraphs, 
kromskopic pictures, 1 casts, microscopic slides, properly mounted mu- 
seum specimens, and cultures of micro-organisms make valuable 
additions to a well-written account of a postmortem. 

If the ascertainment of the cause of death be the object in view, 
the line of inquiry should be based upon a hypothetical or tentative 
diagnosis suggested by the clinical history or special circumstances 
of the case. This may subsequently be corrected, modified, or aban- 
doned as the autopsy proceeds; but the final diagnosis should, of 
course, not be made until the autopsy shall have been completed. 

A lesion found in one portion of the body may indicate the exist- 
ence of pathological conditions in another, perhaps remote, part. For 
example, multiple melanotic sarcomata of the liver are frequently 
secondary to a primary growth in the eye; an embolism in the brain 
often arises from malignant endocarditis; hsematomata of the ears 
will suggest chronic meningo-encephalitis, with thickening of the 
cranial meninges; and the presence of miliary tuberculosis should 
lead one to an examination of the pulmonary arteries for tuberculous 
thrombi arising from caseous tuberculous glands. Again, particles 
of coal-dust embedded in the hands demand a careful inspection of 
the lungs for anthracosis, while bronzing of the skin will suggest 
the careful examination of the adrenals and of the sympathetic gan- 
glia (Addison's disease). 

There are cases in which it is impossible to state positively the 
cause of death, even on the completion of the autopsy, after a most 
thorough and painstaking examination. In such instances, as in all 
others, the accuracy of the conclusions drawn will depend upon the 

1 Cattell, International Clinics, Vol. ii., Tenth Series, 1900. 



GENERAL CONSIDERATIONS n 

care exercised in the observation of details. Fortunately for those 
having to do with cases coming under the notice of the coroner, 
sudden death is nearly always attended with well-marked pathological 
lesions. When no such cause of death is found, chemical or early 
bacillary poisoning should be suspected. Any epidemic disease, such 
as smallpox, which is now (1903) so widely distributed throughout 
America, should always be thought of during the time of its preva- 
lence, as death may occur before the characteristic rash or symptoms 
have made their appearance. 

The opportunities for the study of the appearances and character- 
istics of normal structures offered by postmortems upon the remains 
of healthy persons killed by accident should not be neglected, as a 
thorough knowledge of normal conditions is necessary in order that 
morbid changes or slight variations from health may be recognized. 
Such subjects also often afford favorable opportunities to study dis- 
ease in its earliest manifestations; this is especially true of tumors 
and the infective granulomata. New combinations of anomalies may 
also be found. As the science of medicine advances, new discoveries 
require a constant revision of the statistics of even the most common 
diseases. 

Autopsies likewise present exceptional opportunities for reviewing 
the study of anatomy and even for acquiring dexterity in the practice 
of surgery, — a method much practised by Agnew, Keen, and other 
celebrated surgeons. To this end, it is permissible in suitable cases 
to perform surgical operations that entail no disfigurement or muti- 
lation of the body. Thus, in females an Alexander's operation, 
oophorectomy, symphyseotomy, or hysterectomy may be performed, 
and on subjects of either sex the operator may practise a preliminary 
laparotomy, a laminectomy, and lumbar puncture for diagnostic pur- 
poses or for spinal anaesthesia, or study the technique of stretching 
the sciatic nerve, or of removing the ear-ossicles, the Gasserian gan- 
glion, or the vermiform appendix. Some of the newer surgical de- 
vices, such as decapsulization of the kidney, mechanical irritation of 
the hepatic peritoneum, the Lorenz operation for congenital dislocation 
of the hip. the formation of an anterior and posterior cusp in the 
cervical os to prevent conception, but still permitting the outflow of 
the menstrual fluid, etc., will at once suggest themselves as being 
worthy of practice upon the cadaver as the opportunity offers itself. 

In every instance the first step is to secure a legal right to make 



4 POST-MORTEM EXAMINATIONS 

the examination. When the postmortem is not to be performed by 
order of the coroner or of the court, consent (preferably in writing) 
should be obtained from the next of kin to the deceased, or, in the 
absence of relatives, from the person in charge of the funeral. The 
feelings of friends and relatives must be fully respected, and it should 
be remembered that scientific zeal is no excuse for any procedure that 
may shock those who were intimately associated with the deceased. 
In a recent suit for damages against a Philadelphia hospital where 
a postmortem was made without the consent of the nearest relative, 
the judge severely deprecated the procedure, but held that no damages 
could be recovered from the hospital, it being founded for charitable 
purposes. 

The method to be pursued in gaining permission will depend on 
the nature of the case, but the exercise of tact will nearly always 
secure consent, except where religious bigotry stands in the way. 
Thus, one resident in a hospital will obtain an autopsy upon almost 
every patient dying in the wards during his term of service, while 
another interne of the same institution will, for one reason or another, 
meet refusal in the great majority of his cases. The curiosity of 
relatives and friends may be aroused, or the humane plea of doing 
no harm to the dead and possibly much good to the living will often 
appeal to the better judgment of those from whom the permission 
is to be obtained. The laity should be encouraged to ask for the 
making of an autopsy, which when carefully performed may win 
ready consent to, or even a voluntary request for, other postmortems 
in the vicinity in which the physician resides. The blank forms which 
accompany insurance papers often contain the query, " Was an au- 
topsy made?" and an affirmative answer greatly strengthens the 
holder's claim. The offer of a small sum of money will often secure 
permission to make a necropsy among the indigent foreigners who 
are so numerous in our large cities, but the threat to refer the case 
to the coroner unless permission is voluntarily granted should never 
be employed. 

Dead bodies may have a pecuniary value, and thus give rise to legal 
difficulties. The Supreme Court of California has recently decided 
that a man cannot by will dispose of his own corpse. A man left to 
the managers of a medical college, in the hospital of which he had 
been treated, his body to be used for scientific purposes. When he 
died, the nearest of kin claimed the body, and applied to the courts 



GENERAL CONSIDERATIONS e 

for an injunction restraining the medical college from taking the 
cadaver. The kinsfolk won; the court holding that the custody of 
the corpse and the right of burial belong to the next of kin. 1 There 
are several societies in America, the members of which sign cards 
granting permission for the performance of postmortems on their 
bodies : it would, therefore, seem best on account of this decision 
to have the card endorsed by the legal heirs. And yet circumstances 
may readily occur, even in such cases, to prevent the autopsy. Thus 
in the case of Phillips Brooks, who was a member of the American 
Anthropometric Society, I, as the prosector of the society, on reach- 
ing Boston could not perform the postmortem, as the body had been 
placed in an hermetically sealed coffin owing to his death having 
been caused by diphtheria, and a public funeral was desired by his 
many admirers. There should be a law that all persons dying in 
our public institutions shall be posted. Such a rule exists in the hos- 
pitals in Germany and has recently been adopted, with practically no 
opposition, in Blockley here in Philadelphia. In those cases going 
to the anatomical board care should be taken to preserve the arteries 
for future injection. If in the course of an autopsy conditions are 
found which indicate foul play, as injuries, or the presence of poisons, 
the postmortem should be immediately suspended and steps at once 
taken to have the coroner or other legal officer take charge of the case. 
If properly authorized by the coroner or the person who is legally 
acting as such, the examination may be proceeded with in the manner 
usual in performing medicolegal postmortems. 

When portions of the body are desired for preservation or for 
future study, permission to remove them should be obtained from 
some one connected with the household, though not necessarily from 
the nearest relative, as in gaining consent for the performance of 
the autopsy. It is, of course, unnecessary to tell how much of the 
body is to be taken away! Should, however, the person authorizing 
the autopsy forbid the removal of any portion of the body from the 
house, no specimens should be secured. Consent can nearly always 
be obtained for the removal of small pieces of tissue for microscopic 
purposes, even in those" cases in which permission to take away larger 
specimens is refused. Thus, in the postmortem on President Mc- 
Kinley, the bullet causing the fatal wound was not found, owing to 

1 American Medicine, April 6, 1901. 



6 POST-MORTEM EXAMINATIONS 

Mrs. McKinley objecting — though without legal right so to do — to 
the search being longer continued, and it was only with the greatest 
difficulty that permission was obtained to remove portions of the body 
for microscopic study. 

Professional friends should be invited to be present at an autopsy ; 
under the scrutiny of critical eyes better work is undoubtedly done. 
Besides, in medicolegal cases the responsibility of making an autopsy 
in which the evidence obtained may be sufficient to convict or acquit 
a person of the gravest of crimes is often too great to be borne alone. 

Those present are frequently prone to make suggestions, many of 
which are worse than useless; but it should not be forgotten that 
often two heads are better than one. On the other hand, courtesy 
demands that a guest should not be too forward in offering advice, 
but should be ever ready to render such assistance to the operator 
as he may need or request. 

The interval allowed to elapse after death before an autopsy should 
be performed depends upon the circumstances governing each case, and 
may vary from a few minutes to several days or even months. In 
no case should the examination be deferred longer than is absolutely 
necessary, as the entire cadaver is soon invaded by bacteria, and 
nuclear figures and cellular elements quickly lose much of their value 
for microscopic study. The feeling of warmth, however, imparted 
to the hands of the operator while making a necropsy upon the cadaver 
of one who has just died, especially if there has been much elevation, 
of temperature, as in a case of heat exhaustion or of atropine-poisoning, 
is so repugnant to one's sensibilities that sufficient time should always 
be allowed for the corpse to reach a temperature inconsistent with sus- 
pended animation. In New York State a postmortem must imme- 
diately follow an electrocution inflicted for capital punishment. It 
is popularly believed that in at least one case the man was not posi- 
tively killed by the electric current. The case of Bishop, the so-called 
mind-reader, will also be recalled in this connection, where the post- 
mortem on a cataleptic was made immediately after death. In Ger- 
many at least twenty-four hours must elapse after death before the 
performance of the autopsy. 

The time required for the completion of a postmortem depends, 
of course, upon the conditions under which it is performed, upon the 
nature of the case, and upon the skill of the operator. In favorable 
cases I have removed the brain in less than three minutes from the 



GENERAL CONSIDERATIONS j 

time of making* the preliminary incision, and have made an entire 
postmortem, including the removal of the cord, in a few seconds over 
eighteen minutes. On the other hand, eight hours of uninterrupted 
work have been consumed in the actual performance of one of my 
autopsies. In a hospital the usual time required for a post-mortem 
examination is about an hour and a half. It is stated that Rokitansky x 
performed over thirty thousand autopsies, which would hardly allow 
an average of an hour for each. I have known Kolisko to make five 
or six autopsies in a morning, and have myself performed ten in one 
day. Owing to lack of time, the surgeon or clinician often wishes 
the necropsy to be done with more celerity than is consistent with 
thoroughness, as he merely desires to ascertain a certain fact or to 
observe a single organ. He can generally be accommodated in a 
few minutes and the necropsy afterwards completed in the routine 
manner. 

The place at which a post-mortem examination is to be made is 
rarely a matter of choice, especially in private practice, but it should 
always be where the best light is obtainable. Daylight from the north, 
such as is used by artists, should be preferred. If the autopsy must 
be made after dark, a combination of the electric and Welsbach lights 
is the most satisfactory artificial illuminant. Orth suggests that a 
good substitute for daylight may be obtained by filling a glass flask 
with water slightly colored with methylene blue. Such a flask may 
be used as a condenser so that the rays of light are concentrated upon 
the surface to be examined. One should, however, early become 
accustomed to the changes of color produced by artificial light, as 
shown in one of my autopsies made by gaslight on a subject of poison- 
ing by battery fluid : I was much struck next morning on observing 
how different those tissues stained with bichromate of potassium 
appeared by daylight. In Manchester, England, where the days are 
so often dark, textile workers adopt a number of methods to get true 
color values; one of these consists in passing the light through a 
specially colored glass. 

Time and labor will be saved by making the autopsy before the 
body is dressed for interment, and the undertaker should be directed 
not to inject the body until after its completion. The argument may 



1 Preface to New Sydenham Society's translation of Rokitansky's Patholo- 
gischen Anatomic. Quoted from Brockhaus's Conversations Lexicon, 1854. 



8 POST-MORTEM EXAMINATIONS 

be used to the undertaker that much blood is removed at the autopsy, 
and the appearance of the exposed parts is improved by the gravitation 
of the blood into the larger cavities of the body. Fortunately, the 
formalin injecting fluid now most generally employed for embalming 
purposes does not interfere with the microscopical study of tissues 
as did the old arsenic injection. Indeed, one of the special methods 
for the hardening of the brain is based on its previous injection with 
formalin through a cannula inserted in the orbit or nasal cavities. 

The amount of preparation necessary for an autopsy will depend 
somewhat on whether the autopsy is to be made (I.) in a private 
house or at an undertaker's establishment, (II.) in a hospital or 
morgue. 

I. In the former case a table on which to lay the body is rarely 
available, and a substitute must be provided. If the postmortem be 
not performed as the body lies in the coffin, the coffin-lid or, still 
better, the bottom of the inverted coffin, the wooden slab usually 
found in the coffin, or a door taken from its hinges and placed upon 
two kitchen chairs affords a good substitute for a table. For the 
body of a child the marble slab from the top of a bureau may be 
used. 1 In order that the necessary manipulations may conveniently 
be made, the body must not lie too low, and a piece of oil-cloth, 
mackintosh, or old carpet should be placed under the table or its 
substitute, to prevent soiling the floor. In addition to the articles 
brought by the operator (see page 36), two buckets half filled with 
lukewarm water, an empty basin, and several newspapers should be 
provided. Before work is begun, the relatives and friends should 
be tactfully requested to leave the room. The undertaker or his 
assistant should remain, as he can often render valuable aid in the 
performance of the autopsy. 

Scrupulous cleanliness in the performance of an autopsy is of the 
greatest importance. The reasons for this are apparent. We owe 
a duty to our fellow-men not to leave behind malignant organisms 
in the place where a postmortem has been performed. You can see 
better and feel better if the organs and fingers are not besmeared. 



1 A portable post-mortem table has been invented by Dr. Kley, of Rahden, Kreis 
Liibbecke, Germany (Orth). There are in the market many portable operating 
tables which may also be used for this purpose, as the one described by Sherman, 
American Medicine, October 26, 1901. 





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GENERAL CONSIDERATIONS g 

If the operator be careful not to soil his own person, the sur- 
rounding objects will escape contamination. For this reason he may 
accustom himself in private work to make postmortems without any 
protection to his own clothes. To keep clean there should be a boun- 
tiful supply of water, a basin for the hands, a board on which to 
arrange the instruments in a regular and constant position, and a fre- 
quent use of the sponge, except on mucous and serous surfaces, where 
an g examination should be made previous to the application of water, 
and when the water is applied it should be allowed to flow upon the 
surface without bringing the sponge in contact with it. 

In private work the laity are likely to estimate the skill of the 
pathologist by the neatness displayed in sewing up the body and the 
appearance of the room after the autopsy is completed. The greatest 
care should be exercised that no blood-stains are left behind. In- 
cense or cascarilla bark may be burnt, or ground coffee may be strewn 
on red-hot coals, to remove the odor from the room where the autopsy 
was held, after which the apartment should be thoroughly aired. 

II. In a hospital or morgue the facilities for making an autopsy 
are much more complete. A well-appointed mortuary room, like the 
one at the Aver Clinical Laboratory of the Pennsylvania Hospital 
( Fig. i ) , should contain an operating table, which should be strongly 
built, about seven feet long, two feet nine inches high, and three feet 
six inches wide. The top may be of either slate, zinc, or copper, and 
should slope gently towards a central perforated depression con- 
nected with a drain and a ventilating shaft worked with an electric 
fan. Sunken grooves radiating towards the centre should also be 
provided. (Figs. 2 and 3.) The side upon which the body rests 
should be divided into feet and fractional parts of an inch or into cen- 
timetres. The markings may be made directly on the top of the table, 
or, if slate be used, a metal rule may be sunk into the slate, taking 
care that no edg'es be exposed. For class instruction, a revolving table 
is required, and by an ingenious arrangement of a fulcrum and lever 
attachment the body can be weighed on the table. Several additional 
tables upon which to place instruments, scales, plates, and other requi- 
sites should be provided. 

The refrigerator box should be provided with scales so arranged 
that the body can be weighed within it. At my suggestion the Fair- 
banks Scale Company prepared one of their scales to combine with 
a Ridgeway refrigerator for the Ayer Clinical Laboratory (Fig. 4). 



10 



POST-MORTEM EXAMINATIONS 



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Fig. 5. — Working plans for preparing refrigerator with eight compartments for the storage of bodies 
preparatory to their removal for burial. Front view. 





Fig. 6. — a, guide"; b, track. 



Fig. 7. — Lateral view. 



GENERAL CONSIDERATIONS 



II 



The scales are at one side, against but outside of the refrigerator 
box, so that the body can be weighed while it is in the ice-chest, and 





Fig. 8.— Working plan, prepared by Dr. Drysdale at the request of the writer, for combination elec- 
tric, gas, and water fixture above post-mortem table at the Aver Clinical Laboratory; constructed by 
Horn & Brannen, of Philadelphia. 



with its doors closed. Each box should have two doors, one opening 
into the post-mortem room, and another on the opposite side, through 



12 



POST-MORTEM EXAMINATIONS 



which the body ma}' be viewed by friends and removed by the under- 
taker. (For working plan see Figs. 5, 6, and 7.) 

Illumination for both day and night work should be provided,, 
preferably by a northern skylight and a combination gas-light and 
electric-light fixture directly over the table (Figs. 8 and 9). Plenty of 
running water should be supplied by means of a spigot with rubber 
tubing attached and brought from above within easy reach, so that by 




Fig. 9. — Combination electric, gas, and water fixture to be placed above post-mortem table. 



the use of a mixer a steady stream of either hot or cold water may 
be had without delay and wherever desired. To support the head 
there should be a solid block or a rest such as is used by under- 
takers. This block should be thirty centimetres long, twenty centi- 
metres high, and six centimetres broad. (For children smaller sizes- 
are to be employed.) It is hollowed out on top for the nape of the 
neck to rest upon. Some of the various shapes in common use are 



GENERAL CONSIDERATIONS ^ 

shown later on in Figs. 46, 47, and 109. A board upon which organs 
may be placed after their removal, for convenience in making sections, 
etc., should also be at hand, as the slate slab becomes slippery from 
the fluid exuded and the organs are held with difficulty when incisions 
are made into them. It is the custom abroad to set a stool over the 
upper ends of the thighs, and upon this the instruments are arranged 
within easy reach of the operator. 

To avoid the spattering or dripping of fluids when opening the 
cranium, it will be well to place on the floor beneath the head a piece 
of previously moistened horse-blanket or mop. If the operator be 
subject to rheumatism, he should, while making the autopsy, stand 
on a piece of dry board rather than on the cement or tile floor usually 
found in mortuaries. The latticed wood flooring found on ships is 
well adapted to this purpose. 

A work-table supplied with ordinary chemicals, a desk for the 
post-mortem book, a revolving chair, a slop-sink, a wash-stand, several 
cabinets, and an outfit for preparing frozen sections complete the 
furniture of a well-equipped mortuary. The preparation of the latter 
adds greatly to the interest as well as value of an autopsy by enabling 
the operator to compare the microscopic and macroscopic appearances 
of a part while it is still under examination in a fresh state. The use 
of ethyl chlorid as the freezing agent, where the more elaborate carbon 
dioxid or ether freezing apparatus is not at hand, may sometimes be 
advisable. 1 

1 Cattell, International Medical Magazine, December, 1896. 



CHAPTER II 

POST-MORTEM RECORDS AND NOTE-TAKING 

The three following rules are to be rigidly observed in makings 
post-mortem examinations. 

1. Never disturb any part or organ until its position relative to' 
adjacent tissues and organs has been accurately determined. 

II. Never unnecessarily remove a part or organ if the proper in- 
spection of remaining parts or organs will thereby be rendered difficult 
or impossible. 

III. When it is necessary to cut open an organ in order to examine 
its cavities, walls, or component parts, make the requisite incisions in 
such a way as to permit, as far as possible, the reconstruction of the 
organ in its original shape and condition. 

In the fulfilment of these conditions it is, therefore, best to begin 
by making a preliminary topographical (superficial) examination of 
the cavity and the contents about to be examined. In the case of the 
trunk, the abdominal cavity is inspected first, the thoracic cavity next, 
and the pericardial last, whereas the removal of the organs contained 
in these cavities and their description should be made in the reverse 
order. The abdomen should be examined before the thorax is opened 
in order that the position of the diaphragm and the relative situations 
of the various abdominal organs can be determined before the entrance 
of air into the thoracic cavity has altered the normal relationship and 
the escape of blood and other liquids has obscured the appearances of 
the parts under consideration. If the postmortem is rewritten, any 
descriptions given in the superficial examination may be combined with 
the detailed description of the parts removed from the abdominal cav- 
ity, thus permitting of the omission of any possible repetitions. The 
following characteristics of each organ are to be noted. 

i. Situation and relations to other parts. 

2. Size and weight. 

3. Shape, contour, borders, and coverings (capsule, serosa, etc.). 

4. Color. 

5. Consistency. 

6. Anomalies and malformations. 
14 



POST-MORTEM RECORDS AND NOTE-TAKING 



15 



7. Cut surfaces and liquid exuded. 

8. Odor. 

9. Pathological conditions. 

1. Situation and Relations to other Parts. — This takes into account 
any change in the normal position or attachments of the organ. There 
are a number of regional landmarks frequently used ; thus, in the case 
of the diaphragm we speak of its height in relation to the ribs or the 
intercostal spaces ; of the stomach as extending so many inches below 
the umbilicus ; and of the heart in its relation to the left nipple and the 
xiphoid cartilage. 

2. Size and Weight. — Various means are employed for deter- 
mining size besides actual measurement. Virchow had, in the old 
Charite dead-house before its recent destruction by fire, a cabinet 
containing specimens of various familiar objects, such as beans, peas, 
lentils, etc., with which pathological lesions could be compared. Later 
on, recognizing the relation of specific gravity to size and weight, he 
estimated the size by noting the quantity of water displaced by the 
organ in a flask of known capacity. A number of familiar objects at 
once suggest themselves, which may be used for comparison in de- 
scribing the size of a lesion or part. In the writer's experience, per- 
sons have, as a rule, but a vague idea as to the actual size of familiar 
objects, such as the head of a horse (usually underestimated) or the 
height from the ground of a stationary washstand (usually over- 
estimated). 

For tables of weights and measures of the body, see Chapter XXV. 
Whenever possible, it is advisable to give the dimensions in centi- 
metres and the weight in grammes. It should be remembered that a 
large organ is not necessarily a heavy one. Atrophy and hypertrophy 
may be present in the same part, as seen in those cases of hypertrophic 
cirrhosis of the liver in which acute yellow atrophy has supervened. 

3. Shape, Contour, Borders, and Coverings {Capsule, Serosa, 
etc.). — Here are noted any deviations from the normal. It is often 
advisable to use the name of some familiar object in order to convey the 
idea as to the configuration, — e.g., cauliflower growth, hobnail liver, 
etc. Descriptions of the surface include the external appearance of 
solid organs. The surfaces may be smooth, granular, nodular, shriv- 
elled, puckered, etc. Here we also describe the capsules of the kidney, 
spleen, etc., and the serous coverings of the lungs, heart, uterus, blad- 
der, etc. The borders of organs that have undergone infiltration are 



1 6 POST-MORTEM EXAMINATIONS 

usually rounded and filled out ; in the degenerations they are generally 
flatter, thinner, and sharper than normal. Thus, in fatty infiltration 
the edges of the liver are rounded, while in cirrhosis its margins, often 
so largely composed of connective tissue as to contain practically no 
liver-cells, are sharply defined. The general contour of the blood-vessel 
may be markedly changed, as in aneurisms. 

4. Color. — It is most difficult to describe colors or to reproduce 
them satisfactorily. Various shades of red are the most common colors 
found in the body ; there is no such thing as pure white, even the con- 
junctivae being a pearl-grayish pink. In pathology the word " pale" 
means a minor degree of color. Note the color of the organ as soon 
as possible after exposure, as air, light, and water tend to alter it con- 
siderably, though naturally more or less change brought about by 
death has already occurred. Thus, the transparent living pericardium 
at autopsy is only translucent. An organ should not be washed before 
its color is described, as water washes away part of the coloring mat- 
ter present, acts on the proteids, and modifies the original consistence 
of the organ; these changes may readily be demonstrated by placing 
the thymus gland with the surrounding areolar tissue in running water 
for five minutes. Air oxidizes the blood, so that a bluish stain may 
in a short time change to bright red. In the case of a congested lung 
it is often well to note its appearance both before and after the blood 
has become oxidized. Certain abdominal organs are frequently dis- 
colored by sulphid of iron produced through the precipitation of the 
iron from the haemoglobin by the hydrogen sulphid arising from de- 
composition. In a case of ammonium hydrate poisoning observed by 
the author, although the body was well preserved, the characteristic 
discoloration had penetrated the substance of the liver to a consid- 
erable extent (three-quarters of an inch). 

5. Consistency. — This is learned only by experience, and is deter- 
mined by pinching the organ between the thumb and the index-finger. 
It should be remembered that the consistency is affected by the season 
of the year in which the body is examined, by the temperature of the 
body and of the place where the postmortem is held, by the length 
of the interval between death and the making of the autopsy, by the 
manner of death, and by the method adopted for the preservation of 
the body. 

6. Anomalies and Malformations {Congenital and Acquired). — 
Each part or organ has its own peculiar anomalies and malformations, 



POST-MORTEM RECORDS AND NOTE-TAKING 17 

and an entire chapter might readily be written upon the various 
altered conditions revealed by autopsies. Thus, the writer has seen 
perforation of a typhoid ulcer in a Meckel's diverticulum ; free calcified 
bodies in the abdominal cavity; peculiar curvatures of the iliac ar- 
teries ; the left kidney shaped like the spleen ; the tip of the vermiform 
appendix resting near the pyloric end of the stomach ; an artificial 
anus made by the rupture of a typhoid ulcer ; the vermiform appendix 
in a left femoral hernia and the sigmoid in a right inguinal hernia; a 
fish-bone in the omentum ; etc. 

7. Cut Surfaces and Liquid exuded. — When an organ is incised, 
describe first that which is most striking, as, for example, the presence 
of a hydatid cyst that is exposed on section of the spleen. Note the 
color of the exposed surface; whether it is smooth or granular; the 
amount, character, and chemical reaction of the fluid that is sponta- 
neously exuded or is obtained by scraping with a knife; and the condi- 
tion of the blood-vessels, especially as to atheroma and thrombosis. 
Numerous incisions may lead to the discovery of new lesions or afford 
an opportunity of studying the morbid process in its various stages. 

Under the term " liquid exuded" is included not only blood, transu- 
dates, and exudates that follow on incising the part, but also any fluid 
that may be contained in the cavity of a hollow organ or in a cyst pres- 
ent, and the juice that appears on scraping or squeezing. 

GEdema of an organ may be detected by squeezing it. In the lungs 
a frothy oedema shows the absence of a pneumonic infiltration. Sur- 
faces should be scraped and the material thus obtained examined with 
the microscope. 

In describing cavities pay especial attention to the lining mem- 
branes, noting their color, lustre, smoothness or roughness, and the 
presence of any adhesions ; also the quantity, color, consistence, odor, 
and reaction of their contents and any sediments found therein. 

8. Odor. — It is safe to predict that twenty years hence more atten- 
tion than at present will be given to the significance of odor. The 
organ of smell is poorly developed, and varies greatly in different indi- 
viduals and in the same individual at different times. The peculiar 
odor that accompanies the growth of certain bacteria, such as the 
Bacillus coli communis, is Avell known. Smallpox and measles have 
their peculiar stenches. We may also mention the acetone odor of 
diabetes, the pus-like odor in leucocythsemia, the butyric-acid-like or 
alcoholic odor from the brains of those who have drunk heavilv before 



18 POST-MORTEM EXAMINATIONS 

death, the uraemic odor, the odor in cases of carbolic or hydrocyanic 
acid poisoning, etc. Great care must be exercised to draw a correct 
inference from the odor. Too often a case of apoplexy is taken to a 
police-station and the diagnosis is there recorded as one of alcoholism, 
simply because the odor of alcohol is found on the person arrested. 

9. Pathological Conditions. — From the sum of the characteristics 
previously given we arrive at our diagnosis, which in many if not all 
cases will have to be confirmed by microscopical examination. 

Finally, while it may be .easy to distinguish from which side an 
organ has been taken when there are no marked changes in shape, the 
author has found that much time is saved and confusion avoided by 
marking each of the double organs as it is removed from the body, — 
one nick for the left and two nicks for the right-sided organs. 

In order that nothing of importance shall be missed in the examina- 
tion the pathologist must have a definite plan of survey that he follows 
at each autopsy. The following order of examination has given me 
most excellent results : 

1. Examination of the exterior of the body. 

2. Topographical examination of the abdominal cavity. 1 

3. Topographical examination of thoracic cavities. 1 

4. Pericardium. 

5. Arch of the aorta. 

6. Heart. 2 

7. Lungs, (a) Left, {b) Right. 3 

8. Larynx and trachea ; external examination of the oesophagus. 

9. Mesentery and peritoneum. 

10. Spleen. 

11. Intestines, except the duodenum. 

12. (a) Left adrenal body and semilunar ganglion, (b) Left kidney, (c) Right 

adrenal body and semilunar ganglion, (d) Right kidney. 

13. Ureters and bladder. 

14. (a) In the male : Prostate gland, spermatic cord, urethra, testicles, etc. (b) 

In the female : Uterus, tubes, ovaries, broad ligaments, etc. 

15. Duodenum and its ducts. 

16. Stomach and oesophagus. 

17. Liver. 

18. Pancreas. 

1 At this stage of the examination the organs are not to be incised nor are their 
relations to be markedly disturbed. 

2 While the heart is being examined time may be saved by having an assistant 
undertake the opening of the skull, as, theoretically, the heart should be exposed before 
the head is opened and the brain inspected before the heart is incised. 

8 The pleural cavities, already superficially examined, are to be most carefully 
inspected after the removal of each lung. 



POST-MORTEM RECORDS AND NOTE-TAKING 19 

19. Retroperitoneal glands, the diaphragm, psoas muscle, thoracic duct, thoracic 

and abdominal aortae, venae cavae, abdominal sympathetics, abdominal 
portion of the spermatic duct, etc. 

20. Head, (a) Scalp and skull, (b) Meninges, (c) Encephalon. (d) Eye. (e) 

Ear. {/) Nasopharyngeal cavities. 

21. Spinal cord. 

22. Bones, peripheral nerves, arterial trunks of the extremities, muscles," etc. 

23. Portions preserved, and the character of fluid employed. 

24. Microscopical, chemical, and bacteriological examinations. 

Post-mortem records may be kept in a book specially prepared for 
that purpose, or on sheets to be filed away with the clinical history of 
the case under consideration. In my own practice I have endeavored 
to give each autopsy performed by myself a specific number, and lately 
have preserved my records on sheets kept in a flat-opening note cover- 
book, until they are ready to be filed away and indexed in properly 
made manila covers. The interchangeable sheets in the note-book 
measure seven by eight and one-half inches. By means of an ingenious 
clasp opening in the centre, one end being fixed and the other movable, 
the leaves are held in place by passing the clasp through two small 
circular openings on the left-hand side of the page. When the clasps 
are closed, the leaves can be turned like a book; when open, one or 
more sheets may readily be removed or others inserted. This method 
I find superior to the one of keeping the records in special books or on 
the large index cards which are used by many physicians in preserving 
their private case records. 1 

In post-mortem books prepared for hospital records it is advan- 
tageous to have some memoranda printed at the top of each page if the 
book be a large one or at the top of the left-hand page alone if the 
book be less than ten by fifteen inches, so as to afford ample room for 
notes. In my service at the Pennsylvania Hospital I used the fol- 
lowing : 

1 International Clinics, Vol. iv., Eleventh Series, 1902. 



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POST-MORTEM RECORDS AND NOTE-TAKING 2 I 

The routine order of examination employed in the making of the 
autopsy may then follow, or a card showing this order may be dis- 
played in such a manner as readily to be seen by the one making the 
autopsy and the person to whom the notes are being dictated. 

Figures corresponding to the numbers of the divisions in the list 
can be placed just before the notes describing the lesions to be found 
in the parts under examination. It is important, especially in medico- 
legal cases, to write " examined" or " normal" 1 after the number re- 
ferring to the part under study, even if no lesion exists, as this shows 
that an actual examination of this portion of the body has been made. 

As a general rule, the order above suggested will be found con- 
venient and practical. It must, of necessity, be subject to more or less 
variation, depending on the circumstances of the case. Thus, in coro- 
ner's work it is often advantageous to examine the seat of the suspected 
fatal lesion at once, and afterwards resume the order given above as 
nearly as possible. Again, in autopsies on the remains of those who 
have died from nervous diseases it is often best to remove the brain and 
cord before opening the body. 

Many writers advise the use of more or less elaborate printed de- 
scriptions of the various anatomical regions and organs, with blank 
spaces to be filled in at the time of making the autopsy. This method 
of keeping notes has not in my hands yielded as satisfactory results as 
the one described at the beginning of this chapter. I give, however, 
the following example of a post-mortem record, which was prepared 
in 1890 by Dr. Formad and myself and was in use for a number of 
years at the Philadelphia Hospital. The opposite (right-hand) page 
contained no printed matter, and could be used for more extensive 
descriptions or for the dictated record of the entire autopsy. 

There are on the market, especially in England, a number of printed 
books and forms for this purpose. 

1 Objection to the use of the word "normal" may properly be raised, for what one 
person may consider normal another would class as abnormal, while its use by an inex- 
perienced person might lead to the omission of certain data which might be of use in 
the future. It is, therefore, -well to describe the part in detail. This will not only 
impress upon the obducent the normal appearances, but also lead him to make a more 
critical examination than he otherwise would be likely to do. The comparison of one 
organ with its fellow or of one part of the organ with another is often of value in this 
connection. 



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CHAPTER III 

POST-MORTEM INSTRUMENTS AND HOW TO USE THEM 

Various combinations of post-mortem instruments are found in 
the sets catalogued by dealers, but these, except for the systematic 
work possible only in hospitals and morgues, are more luxurious than 
necessary. In fact, the instruments that are really indispensable are 
very few in number, as a complete autopsy may be performed with a 
penknife and an ordinary wood-saw. Of course, in this field, as in 
surgery, ample opportunity has been offered for the exercise of me- 
chanical ingenuity, and many instruments have been devised for fa- 
cilitating post-mortem work that save much time and render greater 
neatness and exactitude possible. 

The following list contains the instruments, apparatus, and chemi- 
cals most commonly used in the performance of an autopsy. 

Knives. — Section- or Cartilage-Knives. — These should be made 
very strong, with a broad back, blunt rounded ends, and a bulge or 
belly at the outer third (Fig. 10), and should be narrower at the 



Fig. io. — Section- or cartilage-knife, with rounded end. (One-half natural size.) 

attachment of the blade to the handle. For general purposes the 
length of the entire knife should be from seven to seven and a half 
inches (about eighteen centimetres), the handle measuring about four 
inches. The Germans use knives even as long as eleven inches 
(twenty-eight centimetres). A separate rounded expansion for the 
index-finger found on the back of some section-knives is unnecessary 
(Fig. n). The sharp-pointed knife should emphatically be con- 
demned (Fig. 12). When the knives are sent to be sharpened, the 
instrument-maker should be cautioned not to grind them to a point. 
Scalpels, such as are used in dissecting. Those made of a single piece 
— i.e., without wooden, bone, or ivory handles — are to be preferred. 
The brain-knife (Fig. 86) should have a thin blade about ten inches 
(twenty-five centimetres) long, one and a half inches (four centi- 
24 



POST-MORTEM INSTRUMENTS AND THEIR USE 25 

metres) broad, and blunt at the end like a table-knife. This instru- 
ment may also be used for incising the large organs and in opening 




Fig. 1 i.— Cartilage-knife with projection on back upon which the index-finger rests when making incisions. 

(Two-thirds natural size.) 




Fig. 12. — Post-mortem knife with faulty point and without proper belly. (Two-thirds natural size.) 

the cavities of the heart. The brain-knife may be marked in the form 
of a rule and thus serve a double purpose (Fig. 13). An ampntation- 

iirfiiii|;iii|!!i!i ! ii|!'iir''|iir; ir; V['~ |'iiiii!!|ii!i|iiii|iiipi|!iii|!iiipiiiiii|iiii| rte-sp^ 

I 7. 3 4- 5 6- 7 ' B 9 10 II 12 13 'A 15 

Fig. 13. — Coplin's brain-knife marked in centimetres on one side and in inches on the other. (Reduced.) 

knife may be employed in place of a brain-knife, or in removing the 
brain through a trephine opening made in the skull. A Waring bread- 
knife (Fig. 14), which also does good work, may be used for incis- 




FiG. 14. — Bread-knife, useful in incising large organs, as the brain, the liver, etc. It comes in two 
forms, — with both sides meeting at the cutting edge like an ordinary knife, or with one side perpendicu- 
lar and the other slanting for about three-eighths of an inch above the sharp edge, as shown near the 
handle in the illustration. (One-third natural size.) 



ing the larger organs. . A Valentine knife (Fig. 15), which has two 
parallel blades adjustable by screws to keep them the desired distance 
apart in order to cut at will thick or thin sections, is now rarely seen, 
but was much employed before the freezing microtome came into com- 
mon use. Pick's myelotome (Fig. 16) is an instrument with a short 
blade bent nearly at right angles to the shaft, for cutting the spinal 



26 



POST-MORTEM EXAMINATIONS 



cord squarely across instead of in an oblique direction. A curved 
probe-pointed bistoury is used in cutting the dura mater, spinal cord, 




Fig. 15.— Valentine's knife. (One-half natural size.) 



Fig. 16.— Pick's myelotome. This little instrument is useful for severing the spinal cord in the removal 
of the brain. (One-half natural size.) 

etc. A razor was formerly included in all lists of post-mortem instru- 
ments, but is now discarded. 

Saws. — The saw should possess a strong blade solidly attached to 
the handle (Fig. 17), as the two-piece jointed ones, kept in place by a 
screw, are very liable to become loosened. A butcher's meat-saw, 




Fig. 17. — A very desirable saw for post-mortem work ; it is solidly constructed, and the teeth on the 
curved end are useful in sawing out the angles in the removal of the skullcap by the angular method 
described on page 166. (Slightly less than one-half natural size.) 



which is arranged like a scroll-saw (Fig. 18) with its teeth pointed 
towards the front, its cutting surface measuring from ten to fourteen 
inches (twenty-five to thirty centimetres) for an adult and six inches 
(fifteen centimetres) for a babe, or a large cross-cut carpenter's saw, 
does the quickest work in removing the calvaria. Hey's saw (Fig. 19) 
is useful in sawing the angles when opening the skull. A metacarpal 
saw (Fig. 20) is often of service, especially in examining the femur 



POST-MORTEM INSTRUMENTS AND THEIR USE 



27 



of a babe for syphilitic osteochondritis. Liter's double rhachiotome 
(Fig. 21), used for opening the spinal column, consists of two parallel 




Fig. iS. — Butcher's saw, very useful for quick work in opening the calvarium. 
(One-quarter natural size.) 




Fig. 19.— Hey's saw. (Two-thirds natural size.) 




Fig. 20. — Metacarpal saw. (Slightly less than two-thirds natural size.) 




Fig. 21. — Luer's double rhachiotome. This instrument is held in the right hand and steadied by 
means of the handle attached to the fixed blade, the other blade being movable by clamps, so that the 
distance between the parallel blades may be varied at the will of the operator. 



saws with curved blades, the distance between which can be regu- 
lated by screws, and a very firm handle with a strong central support. 



28 POST-MORTEM EXAMINATIONS 

Various forms of dental and trephining engines, usually driven by 
electricity, have recently been introduced and are useful in saving time 



Fig. 22. — Cryer's electrical surgical engine for cutting bone. A, spiral osteotome, with guard, for 
removing section of skull ; B, spiral osteotome ; C, trephine ; D, guard for osteotome ; E, electric motor ; 
F, crank for hand propulsion ; G, driving wheel for hand propulsion. 

and labor. Among such engines may be mentioned those of Cryer 1 
( Fig. 22 ) , de Vilbiss, Wright, etc. These instruments are high-priced 



1 Medical News, January 30, 1897. 



POST-MORTEM INSTRUMENTS AND THEIR USE 2 g 

(from one hundred to three hundred dollars), on account of the in- 
frequent demand for them. Hand-driven instruments may be pur- 
chased for twenty-five dollars and upward. 

Scissors. — One pair of scissors should be large and strong, with 
long handles and short, stout blades (Fig. 23) ; the other pair should 





Fig. 23.— Strong scissors with short 
blades. (One-half natural size.) 



Fig. 24. — Scissors with one rounded blade and 
with bent handles. (One-half natural size.) 



have rounded ends with bent handles (Fig. 24). A pair with one 
probe-pointed blade is frequently useful. The enter otome is a scissors 
with one short and one long blade (Fig. 25), the latter being blunt 
and curved on itself at the end. Be sure that there is no sharp-pointed 
end, as this is the form usually supplied (Fig. 26). The costotome 
(Fig. 27) is an expensive instrument, with short, thick blades, the 
under one being curved and having a strong spring between the 
handles. Dangerous blood-blisters are sometimes produced by pinch- 
ing the skin with the ends of the handles, which usually meet and 



30 



POST-MORTEM EXAMINATIONS 





Fig. 25. — Proper form of enterotome. 
(One-half natural size.) 



Fig. 26. — Improper form of enterotome, with 
pointed ends. (One-half natural size.) 




Fig. 27. — Proper form of costotome ; the handles do not meet by one-quarter of an inch and the ends 
are not pointed, but rounded. (One-half natural size.) 



POST-MORTEM INSTRUMENTS AND THEIR USE 3T 

fasten with a catch (Fig. 28). The ends should not meet and there 
is no necessity for the catch. 




Fig. 28. — Improper form of costotome, with pointed blades and a catch, the handles meeting when they 
are closed. (One-half natural size.) 

Hammers. — The most useful hammer is made of solid steel (Fig. 
29). One end of the head or striking portion is cuneiform, and there 
may be a hook on the end of the handle which is of service in spring- 




Fig. 29. — Steel hammer with proper handle. (One-half natural size.) 



ing off the calvarium. Lead filling in a hammer muffles the sound of 
its impact and prevents rebounding. A wooden mallet is preferred by 
some pathologists. 

Chisels. — There are chisels of various patterns devised for use in 
different regions. The straight cliisel is the most serviceable, as it can 
be used in any region. The T-shaped chisel is also generally useful; 
it has one arm placed perpendicular to the other, and the arm which 
serves as a handle has one sharp and one blunt end so that it can be 
hammered upon. The chief use of the T-shaped chisel is in springing 
off the calvarium and in elevating the periosteum from it. Guarded, 
hatchet-shaped, and other chisels (Figs. 30 and 31) and spinal 



32 



POST-MORTEM EXAMINATIONS 



chisels (Fig. 32) are useful in opening the spinal canal, and a chisel 
with a guard about half an inch, or 1.25 centimetres, from the edge 



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m 




Fig. 31.— Cur\-ed chisel, 
used for the same purposes 
as Fig. 30. (One-half natural 
size.) 



Fig. 30. — Solid steel side 
chisel for breaking through any 
unsawed portions of bone in re- 
moving the calvarium. The 
pointed end is used as a pry and 
retractor for pulling out the 
sawed-off portion of the skull. 
(One-half natural size.) 



Fig. 32. — Brunetti's curved spinal 
chisel, of use in opening the vertebrae. 
(One-half natural size.) 



will not injure the brain while springing off the calvarium from the 
dura mater. The raspatory of Chiara has a broad, spoon-shaped end, 
four centimetres wide, with which the periosteum from a large surface 



POST-MORTEM INSTRUMENTS AND THEIR USE 33 

can easily be removed; the other end is of the shape of a lance, one 
inch (2.5 centimetres) long, and is used for deep separation. 

Forceps. — Dissecting forceps are indispensable when it is neces- 
sary to trace small structures; pointed, straight and curved forceps 
are the forms in use. Bone-forceps, large and strong and with rough 
handles, are necessary. One blade is blunt, so that it can be shoved 
against soft tissues without injuring them, as in cutting the ribs. 
Lion-forceps of special type may be used when removing the bodies 
of the vertebra?. Dura-tongs, for pulling the dura mater away from 
the calvarium when it is adherent, may save the fingers from being 
injured by the bone. 

Grooved and curved directors are frequently necessary. 

Chain hooks and a tenaculum may be of use, but they are dan- 
gerous instruments. Hooked retractors are more desirable than a 
tenaculum or chain hooks. 

Various Instruments. — A metal catheter and several flexible 
catheters, all of size number 8, may be needed for withdrawing urine. 



Fig. 33.— Satterthwaite's calvarium clamp, closed and in use. 

A blow-pipe with a stop or valve, a trocar and cannula, probes, some 
of which have eyes, and some form of injecting syringe are also 

3 



34 



POST-MORTEM EXAMINATIONS 



useful. A vise is serviceable in firmly holding bone preparations in 
course of dissection, and in fixing a saw that is being sharpened. A 
skull clamp is considered by some to be of use in removing the calva- 




Fig. 34. — Iron clamp to be applied to the skull before the removal of the brain ; especially used in 

dissecting rooms. 

rium (Figs. 33, 34, and 35). Iron tripods and other special devices 
for holding the head are shown in Figs. 36 and $J. 




Fig. 35. — Bigelow clamp for holding the 
head in the removal of the brain. 




Fig. 36. — Folding iron head-rest 



Weights and measures of various kinds are frequently found to be 
indispensable. These should include scales, a steel tape measure, grad- 







'' 


VPS Mt < J 


_ Jf - — y^~ 









Fig. 37. — Cornell folding clamp for the secure holding of the head in the removal of the calvarium. 




p IG _ 38.— Cones for measuring orifices. (Actual size.) 




Fie;. 39. — Glass balls to which handles are attached, for measuring orifices. 



POST-MORTEM INSTRUMENTS AND THEIR USE 35 

nated calipers, graduated glass cones, glass balls, and graduated meas- 
uring vessels of glass. The scales should have a capacity of twenty 
pounds, or ten kilogrammes, and be supplied with weights from a 
gramme upward. They are needed in weighing organs. The steel 
tape measure and the two-feet rule are marked in both centimetres 
and inches. Graduated calipers are useful in determining diameters. 
Graduated wooden cones are used in measuring orifices (Fig. 38). 
Glass balls are serviceable in determining the size of apertures and 
canals (Fig. 39). Graduated measuring vessels of glass are desirable 
The larger vessels should be marked at every hundred cubic centi- 
metres up to one or two litres, and the smaller for every two cubic 
centimetres up to a hundred. A stomach-pump is especially useful in 
withdrawing fluids from cavities. Ladles w r ith a lip or spout, made of 
enamelled or agate ware, and with a capacity of half a pint, or two 
hundred and fifty cubic centimetres, are needed in dipping fluid from 
cavities. 

A magnifying- glass that enlarges at least ten diameters should be 
in the hands of every one making postmortems. 

Other Supplies. — Enamelled trays or basins are useful for re- 
ceiving removed organs, and the basins are also required in cleansing 
the hands and instruments. Blocks of wood are required to support 
the body. Some of these should be prismatic in form, others excavated 
to fit under the neck during removal of the brain. All wooden utensils 
should be finished with oil so as to be non-absorbent. Earthenware 
plates or zvoodcu boards are useful during the dissection of organs. 
Needles and coarse flax thread or fine twine are needed in closing in- 
cisions made through the skin. The thread is also required in ligating 
the intestines before removing them. Sponges are a necessity readily 
procured, and should always be moist when in use. Pins are useful 
in fixing small structures in course of dissection. Special tables of 
zinc-covered wood, slate, iron, or glass are desirable in a pathological 
department. Rotating tables are convenient, but weighing tables are 
expensive. The table should be constructed so as to carry off all fluids 
into a receptable provided, for them. 

Rubber gloves that reach well up the wrist and finger-cots afford 
protection to the pathologist, particularly in cases where the danger of 
infection is great ; but the operator can work more swiftly with bare 
hands, the abrasions upon which have been protected with flexible col- 
lodion containing two per cent, of iodoform. It is also an advantage 



^6 POST-MORTEM EXAMINATIONS 

to introduce cosmoline into the crevices around the finger-nails. The 
gloves are more readily put on and are preserved by dusting them 
freely with ground soapstonc kept in a dusting bottle. Quart museum 
jars are useful for holding specimens to be preserved, and two-ounce, 
wide-mouth bottles, for microscopic specimens. A clean glass bottle 
with a glass stopper and sealing-wax to keep it closed are needed to 
receive the contents of the stomach in a case of poisoning. Bromin 
in a strong bottle with a ground-glass stopper that fits well serves a 
good purpose in disinfecting fresh wounds. 

Pails are needed as containers for water and to receive fluid re- 
moved from the body. Cotton wool, sawdust, or tow placed in the 
large cavities of the body before they are closed prevents the escape of 
fluid from them. Plaster of Paris and sand serve a similar purpose in 
the cranial cavity. Disinfectants and deodorants should not be for- 
gotten, as it is desirable to destroy or neutralize odors emanating from 
the body, and to disinfect and deodorize the hands of the pathologist 
after the examination has been completed. Bellows are occasionally 
useful in inflating hollow viscera. A hand-bag which can be cleansed 
is required in carrying instruments to and from private houses. 

The chemical, bacteriological, and microscopic supplies required in 
the work of the pathologist at the postmortem are red and blue litmus 
paper, turmeric paper, Lugol's solution, solution of sulphid of ammo- 
nium for detection of free iron derived from bile pigment, as in perni- 
cious anaemia, Gabbett's solution, carbol-fuchsin, Loerner's alkaline 
blue, absolute and commercial alcohol, ethyl chlorid or methyl chlorid, 
culture-tubes containing blood-serum, agar, and gelatin (bouillon is 
troublesome to carry), an alcohol-lamp, glass slides and covers for 
microscopic specimens, filter-papers three or four inches in diameter, 
an old scalpel which can be heated, a platinum wire three inches (or 
eight centimetres) long, set in a solid glass rod six inches (or fifteen 
centimetres) long, for making cultures (called an ose), a microscope, 
a freezing microtome, and easy access to an incubator. 

In my own experience it has been found desirable or convenient 
to discard one instrument after another until now my satchel for 
private work weighs with its contents but nine pounds, and con- 
tains the following articles: two section-knives in good condition; 
a scalpel; a pair of medium-sized, strong scissors; a pair of bone- 
forceps; a dissecting forceps; a saw; an enterotome; a hammer 
with a hook on its handle; a pelvimeter; a new rubber catheter; 



POST-MORTEM INSTRUMENTS AND THEIR USE 37 

gummed labels; various kinds of litmus paper; sealing-wax; a 
dissecting-apron and sleeves ; a pair of rubber gloves, with plenty of 
ground soapstone in an iodoform dusting bottle; finger-stalls; a 
piece of thin rubber sheeting forty-five by thirty inches; a piece of 
oiled silk, or a rubber bag (sixteen by ten by four inches) from which 
fluid will not escape; two medium-sized bath-sponges; a quart 
museum jar graduated into ounces or cubic centimetres, into which 
some of the smaller articles are placed and which can be used for the 
removal of gross specimens later, if desired; a large needle and flax 
twine, cut and wrapped (Fig. 40) into three lengths, for sewing the 




Fig. 40. — Hemp twine cut of the proper length and ready for use. 

body with single thread (forty-five inches), for sewing the head 
( twenty-five inches ) , and for tying the intestines ( ten inches ) ; some 
bromine in a strong bottle with a well-fitting ground-glass stopper; 
two per cent, iodoform celloidin solution ; a small roll of cotton ; four 
two-ounce, wide-mouth bottles for microscopic specimens, one of 
which should be filled with seventy per cent, alcohol, one with ten per 
cent, formalin, one with Muller's fluid, and the fourth with a saturated 
solution of mercuric bichlorid; two ounces of creolin; a cake of one 
per cent, bichlorid of mercury soap ; an ose ; an alcohol-lamp ; several 
culture-tubes properly packed; incense powders; matches; pins, 
saf ety and ordinary ; a steel tape-measure marked in inches and centi- 
metres ; a hand lens magnifying about ten diameters ; a pair of spring 
scales weighing up to fifteen pounds ; and last, but not least, a note- 
book and several pencils, one of which will write on glass. To this list 
may be added other articles as the necessities of the case may demand. 
For the private use of the general practitioner, a large section- 
knife, a scalpel, an enterotome, a saw, a chisel, a mallet, a pair of 
scissors, and a large needle may be purchased for about five dollars. 
These should be kept rolled up in a piece of chamois-skin, preferably 
made with pockets into which the instruments fit, and if the latter be 



38 



POST-MORTEM EXAMINATIONS 



put away clean after use they are always ready for service; or a 

leather case (Fig. 41 ) may be employed. 

The proper handling of post-mortem instruments is not acquired 
in a day, and the beginner will find that 
experience teaches many lessons which are 
not likely to be forgotten. A well-ground, 
keen-edged knife is a great desideratum, the 
advantages of a dull knife being simply that 
it is less likely to injure a beginner or care- 
less operator and to disfigure the exposed 
portions of the body. 1 

In opening the body the free incisions 

should be made by an easy, untrammelled 

movement, executed by the muscles of the 

I shoulder rather than by those of the arm 

or hand. It is essential that the knife be 
grasped firmly (Fig. 42), and not held 
like a pen, as is a scalpel in the act of dissect- 
ing. Virchow says that the knife should 
be held in the whole hand, so that when the 
arm is stretched out the blade extends with 
it. The fingers and hands are fixed, if not 
absolutely, at least relatively, and execute 
the motion with the whole arm, so that the 
movement is principally in the shoulder- 
joint and secondarily in the elbow- joint. 
Thus the whole strength of the arm and 
shoulder muscles is brought into play, and 
long, smooth incisions, so essential to proper 
inspection, are made. In cutting, pressure 
should be uniform, and the greater the 
pressure the quicker will the knife pass 
through the tissues. A clean cut made in 
the wrong place does less harm than a 

ragged one in the right place (Virchow). The portion of the blade 

near the handle should be used for work which dulls a knife, as cutting 




Fig. 41. — Formad's leather 
pocket-case, holding the Instru- 
ments usually employed in making 
a postmortem. (One-half natural 
size.) 



1 The method of holding and using the instruments will be seen illustrated by 
reference to the pages treating of the examination of the various organs. 



POST-MORTEM INSTRUMENTS AND THEIR USE 39 

the ribs. This also applies to scissors, the part near the pivot being em- 
ployed in all cases in which considerable force is required. When held 
as shown in Figs. 47 or 49, but preferably as in Fig. 47, the operator is 
sure to have a firm grasp of the knife-handle, so that there will be little 
likelihood of a dangerous slip. The actual cutting is properly and 
mainly done with the belly of the knife about one inch from its end, for 
which reason this part of the blade is always the thickest. The direc- 
tion of the incision should invariably be from the operator, especial care 
being taken not to wound the left hand, and from those portions of the 
subject in which disfigurement would be most likely to be noticed. 
Care must also be taken not to injure the assistants or those standing 
near. When the resistance of a tissue is unexpectedly overcome, the 
knife will sometimes travel a considerable distance before it can be 
stopped by an effort of the will. 

The blade of the knife must be kept free from blood by frequent 
washing. This is especially necessary when incising organs, as the 
brain, in which incisions are made with much more satisfaction if the 
knife-blade be previously moistened. A pointed knife may be used for 
the removal of the tongue and the larynx, and a scalpel for fine dis- 
section, as in tracing the spermatic or thoracic duct. 



CHAPTER IV 

THE CARE OF THE HANDS AND THE TREATMENT OF POST-MORTEM 

WOUNDS 

Before beginning the autopsy, especially in a purulent case, the 
pathologist should carefully examine his hands ; if these be not in good 
condition, the notes may be dictated by him while some one else can 
usually be found to do the actual cutting. 

For the protection of their patients, residents during their term of 
service in the surgical and gynaecological wards of our hospitals should 
be forbidden to make autopsies, and they should not be tempted to 
break this rule by a request to assist at a postmortem, even though no 
one else be available to do the routine work of opening the body. 

Slight wounds on the hands may be protected before beginning- 
the necropsy by placing a small piece of absorbent cotton upon them 
and then applying the ordinary thick celloidin used in bacteriological 
work, or the iodoform celloidin referred to on page 37. 

Before starting work upon the body, many pathologists anoint 
their hands with some antiseptic salve, such as vaseline containing- 
boric acid, ten grains to the ounce, a ten per cent, carbolic acid oint- 
ment, or a solution of the balsam of Peru. If these be used, they 
should be renewed several times during the progress of the autopsy. 
It is, however, doubtful whether the advantages gained by their em- 
ployment are not more than offset by the fact that the hold upon the 
instruments is thereby rendered less secure. This can to a certain 
extent be avoided by anointing the entire left hand (which comes in 
contact with the tissues of the body) and only the back of the right 
hand (the instruments being held by the palm of this hand) with the 
ointment, as it is here that infection usually takes place when no 
mechanical injury to the hand is inflicted. Frequent washing of the 
hands in clean water is regarded by many as decidedly better. Of 
course, when digital examinations are necessary, as in exploring fistu- 
lous tracts, examining the vagina and os, and in certain cases of peri- 
tonitis, antiseptic unguents are desirable; in such cases it is necessary 
to anoint only that portion of the hand which comes in contact with 
the tissues under examination. 
40 



CARE OF THE HANDS 4I 

An equally efficient and in many respects a much better safeguard 
against infection is the use of rubber gloves. Post-mortem gloves 
made of thin gum elastic and provided with long sleeves may be found 
in the rubber stores and at instrument-makers'. They fit snugly, and 
are especially desirable in opening the stomach and intestines, as it is 
most frequently the intestinal contents which impart the odor that 
adheres so persistently to the hands. They do not prevent, though 
they to a certain extent hinder, the production of post-mortem wounds. 
Rubber finger-stalls, especially the variety known as the seamless rolled 
finger-cot, which unrolls as it is placed on the finger, are useful if the 
operator have any hangnails or other abrasions of the fingers. Blood, 
pus, or other cadaveric fluid should not be allowed to dry upon the 
instruments used nor upon the hands, for it not only impairs the deli- 
cacy of touch so desirable in this work, but it also may cause unsightly 
stains upon the skin, which are difficult to remove, especially when 
certain preservatives have been employed in embalming the body. 

Odor can usually be removed from the hands by applying to them, 
while still wet, either a few drops of turpentine, formic aldehyde, from 
one to three per cent., aromatic spirit of ammonia, listerine, paregoric, 
or mustard, and then washing them thoroughly with a good glycerin 
soap. Neelsen (quoted by Nauwerck) states that, if the odor can 
be removed in no other way, equal parts of fuming hydrochloric acid 
and glycerin should be used. The employment of equal parts of hypo- 
bromite solution (used in the quantitative estimation of urea) and of 
water, while severe, is also very effective for this purpose. 

For disinfection of the hands after the postmortem one may use 
creolin water, made by placing about an ounce of creolin in a basin 
of tepid water, 1 or a concentrated solution of potassium permanganate, 
and the removal of the brownish discoloration can be accomplished 
with oxalic acid or an antiseptic soap. Of the latter, I prefer the one 
per cent, bichlorid of mercury soap. 

A post-mortem wound as usually referred to means not only a cut 
or injury received at a postmortem, but the additional inoculation of 
any break in the continuity of the skin by means of which pathogenic 
bacteria derived from the dead bodies of human beings or of animals 
gain entrance to the system and there multiply. Wounds presenting 
similar appearances may, of course, be derived from many sources, as 

1 Or, more exactly, a two per cent, creolin solution. 



42 POST-MORTEM EXAMINATIONS 

from surgical operations and from other post-mortem wounds. The 
intact skin of the hand is a perfect protection against the invasion of 
bacteria. In order that the organisms may infect the body, there 
must be both a point of entrance and a predisposition of the individual. 
While any of the infectious diseases may be contracted in making a 
postmortem, those most to be feared are tuberculous warts, syphilis, 
gonorrhceal ophthalmia, tetanus, anthrax, glanders, plague, actinomy- 
cosis, typhus fever, diphtheria, yellow fever, cholera, and smallpox. 

Inoculations from serous surfaces are especially to be guarded 
against, as from some of the varieties of peritonitis due to criminal 
abortion, and other forms of septic peritonitis, meningitis, or pleurisy. 
Among other virulent forms of post-mortem wounds may be men- 
tioned those derived from cases of pyaemia, of septicaemia, of puer- 
peral fever, of malignant oedema and diffuse cellulitis, of erysipelas, 
and of gangrene. Personally, I have the most wholesome respect for 
the Bacillus pyocyaneus, with which I became inoculated from a case 
of cancer of the gall-bladder with secondary infection by this organism. 
For a number of days my temperature was above 105 F. 

It is often asked why post-mortem wounds and injuries received 
in the performance of similar operations are more dangerous than 
those which are otherwise inflicted. Their greater virulence may in 
part be due to the fact that they are usually punctured wounds, and 
thus afford a favorable opportunity for the deep implantation of pyo- 
genic organisms. Again, it is a well-known bacteriological fact that 
many organisms become more virulent by passing through successive 
animals, and finally, an organism which has overcome the resistance 
of the tissues and killed them is naturally more destructive than one 
which has not had such favorable opportunities for growth. 

Post-mortem wounds are generally caused in one or other of 
four ways: first, by cuts from instruments used in the making of 
the autopsy, especially sharp-pointed knives and the saw; second, by 
scratches or punctures from ragged bones or calcified tissues, as the 
ribs or atheromatous patches of the aorta which have undergone cal- 
careous infiltration; third, by inoculation of pre-existing wounds, 
abrasions, small eruptions, especially at the roots of the hair-follicles, 
hangnails, blisters, fissures in chapped hands, etc. ; and, fourth, by 
cuts and scratches accidentally inflicted by the operator on his assistant, 
as in opening the head. Indeed, so frequently does the latter occur 
that I always dispense with a helper to steady the head unless his hands 



TREATMENT OF POST-MORTEM WOUNDS 43 

"be thoroughly protected by some covering, such as a towel. Ragged 
wounds, such as those caused by the saw or by bones, are especially 
to be dreaded, for, being both punctured and lacerated, they are par- 
ticularly prone to become infected. 

Then, too, it has been shown experimentally that bone marrow 
possesses marked bactericidal properties. Hence wounds produced by 
sharp spicules of bone are usually severe, for the reason that they 
introduce into the wounded tissues large numbers of bacteria by 
which this resistance of the bone marrow has already been overcome. 
The micro-organisms found at a postmortem made several days after 
death are apt to be less virulent than those encountered soon after dis- 
solution, the saprophytes having now gained the upper hand. Other 
things being equal, the more quickly the patient died after infection, 
the more severe will be the post-mortem wound; but the character 
of this lesion and the nature of the organism must always be con- 
sidered. Undoubtedly, persons making many postmortems become 
immune to inoculation by the ordinary Staphylococci and Streptococci. 
When toxins are introduced along with the bacteria, the constitutional 
symptoms are apt to be more severe, as the toxins overcome a certain 
amount of reserved force of the tissues which might otherwise be used 
in combating the organisms themselves. 

Some of the usual ways of producing wounds which are especially 
worthy of mention are : by the operator cutting towards instead of 
away from himself or his assistant ; by leaving the knife in one of the 
cavities and forgetting its presence; by placing his instruments in a 
dangerous position on the body, the table, or the ice-box; by the use 
of sharp-pointed knives; by punctures from the needle, made during 
the sewing up of the body; and by the too rapid passage of thread 
through the hands producing a sort of brush-burn. 

The great protection afforded by the bleeding of a wound is well 
known; hence the immediate closing of the latter by the application 
of caustics or of celloidin is worse than useless. If the finger be 
wounded, it should be wrapped with a miniature Esmarch bandage 
and then allowed to bleed freely under running zvater for at least five 
minutes. Sucking of the wound may then be practised, and, if a 
caustic be required, there is probably nothing better than glacial acetic 
acid or pure formalin. The use of the actual cautery is advisable in 
some cases, but must be so thoroughly applied that no organisms are 
left behind, as otherwise the necrosed tissue may afford a favorable 



44 POST-MORTEM EXAMINATIONS 

medium for their growth. An antiseptic dressing may then be applied r 
which should be renewed every twelve hours. On the slightest indica- 
tion of pus or a deadish-gray appearance of the wound, it should be 
freely incised, thoroughly cleansed with hydrogen peroxide, bromine, 
or formalin, and dressed with iodoform and a wet bichloride bandage ; 
or a solution of silver nitrate may be applied with benefit. I have seen 
no good effect from the local use of the unguentum Crede (ointment 
of soluble metallic silver). The injection of formalin in cases of septi- 
caemia is well spoken of. The frequent application of hot flaxseed 
poultices containing a teaspoonful of Labarraque's solution is most 
grateful when the wound is discharging. Several inches above the 
wound a ring of iodine should be plentifully painted. 

Involvement of the lymphatics, as seen by red lines running up the 
arm, usually on the inner surface, and tenderness in the axilla, indi- 
cates danger. Inflammation of the lymph-glands of the axilla may 
cause the glands in this region to become tender and swollen, so that 
an incision is necessary ; and in cases of axillary cellulitis, even though 
the wound of inoculation be small, early incision should be employed. 
Quinine is useful in these cases, and iron may be prescribed later. The 
affected arm should be carried in a sling, tonic treatment with changes 
of air instituted, and a surgeon consulted, who will treat the case 
according to the character of the wound, the nature of the infection, 
and the constitution of the patient. When healing has commenced, 
massage has made many a useful finger or hand out of what would 
otherwise have been a stiff and useless one. 

The general health has much to do with the severity of the wound, 
and, other things being equal, severer symptoms and slower convales- 
cence may be expected in those who are habituated to the use of 
alcohol. 

The anatomical wart is a local tuberculous lesion, often multiple, 
and situated on the back of the hand or at the flexor joints of the 
fingers. There is a warty thickening of the papilla of the skin, accom- 
panied by a discharge of thin serous pus, but with no true ulceration, 
The sensation produced is similar to that caused by a splinter, which, 
however, subsides for several days after the removal of the fluid con- 
tents. The lesion sometimes heals spontaneously, but may give rise, 
as in one of my cases, to general tuberculosis. Wet dressings, com- 
bined with an application of equal parts of glycerin and extract of 
belladonna, may be employed, or the following mixture applied : 



TREATMENT OF POST-MORTEM WOUNDS 45 



R Salicylic acid, 10 parts ; 
Extract of cannabis indica, 
Cocaine hydrochlorate, of each 1 part ; 
Oil of turpentine, 5 parts : 
Glacial acetic acid, 2 parts ; 
Collodion, 100 parts. 

It would be interesting to try the hypodermic injection of tuberculin, 
or some of the newer forms of treatment for lupus of the face, as that 
recommended by Dr. Finsen. 1 In one of my cases I thought that an 
anatomical wart was rendered worse by the use of the X-rays. 

One of my patients evidently contracted a tuberculous wart from 
a cow, thus adding another case against Koch's dictum which he 
announced at the meeting of the Tuberculosis Congress in 1901. 

When tuberculous warts have lasted several months, surgical treat- 
ment should be instituted, care being taken not to open them into trie 
circulation, and that sufficient healthy tissue be removed to make a 
.good cicatrix. Guinea-pigs injected with such material linger a long 
time, and in one of my cases over six months elapsed before the animal 
died from general tuberculosis. 

Suppuration of the matrix of the nails can often be cured only by 
the removal of the nail, though frequent soaking of the finger in a 
hot saturated solution of boric acid or a strong solution of lead sub- 
acetate may be tried. Diffuse cellulitis should be treated by early and 
free incision and the application of cold compresses. When the hand 
itself is involved in spreading gangrene, amputation should usually 
be practised. I have seen septicaemia, pyaemia, general tuberculosis, 
ulcerated endocarditis, purulent meningitis, boils, whitlows, etc., fol- 
low post-mortem wounds. 

If the knives used in post-mortem work were thoroughly sterilized 
after each necropsy, there would be fewer infected wounds. The 
making of autopsies is undoubtedly dangerous, and therefore those 
who are in the habit of doing so should insure themselves in one or 
other of the' accident companies which contain a clause giving a claim 
for benefits in case of wound-infection. As these companies show a 
disposition to dispute claims, any injury, no matter how slight it may 
be, should be reported to them as soon as possible after its occurrence. 

1 Bie. International Clinics, Vol. iii., Eleventh Series, 1902. 



CHAPTER V 

EXAMINATION OF THE EXTERIOR OF THE BODY 

After carefully considering the clinical history and weighing the 
evidence derived from an examination of the surroundings and from 
questioning the persons who have been brought in contact with the 
corpse, the nude body should be minutely inspected, first as a whole 
and then with regard to its component parts. 1 This external examina- 
tion is of especial value in medicolegal cases or when the postmortem 
is about to be performed upon an unidentified body. The noting of 
certain details, such as moles, birth-marks, angioma, tattoo markings, 
scars, condition of the teeth, and anomalies of the ear and eye, may 
be of great importance, and may even later on be the sole means of 
identifying the body. Should the clothes be preserved for any reason, 
as for purposes of identification or for showing the entrance of a 
bullet, camphor or tar camphor should be added previous to their being 
securely wrapt up and properly labelled, in order to prevent their de- 
struction by moths. In handing them over to the proper legal officers 
it is well to get a receipt for such articles and to have the transaction 
take place in the presence of a witness. The knowledge acquired by 
inspection of the surroundings and the exterior of the body must, 
however, in no way bias the examiner in his internal examination, as 
the unexpected happens here as elsewhere. 

The sex, the race, and the apparent age 2 are first carefully noted. 
The height is now determined by measuring in a straight line from the 
vertex of the head to the centre of the external arch of the instep. If 
a scale is not marked on the table and no other means of measuring is 
at hand, a piece of inelastic string or tape may be employed for this 

1 It would be well if the living body were more frequently made the subject of 
careful study in the nude state, as the information thus obtained is often of great 
value to the clinician or surgeon. 

2 By apparent age is meant the age of the body as it appears to the judgment 
of the observer at the time of making the postmortem. Thus, a person may look 
younger or older than his or her real age, suffering, mental depression, etc., often 
making the body seem many years older than it really is. Per contra, the signs of 
suffering may pass away and the features become relaxed and appear in better 
condition than for years before death. 

46 



EXAMINATION OF THE EXTERIOR OF THE BODY 47 

purpose and measured later. The writer would suggest the use of a 
measuring apparatus modelled on a shoe-measure. A simpler form 
can readily be made by taking two one-foot rulers, or other sticks of 
about the same size, and attaching, one inch from one end, a seventy- 
eight inch tape-measure, 1 which is made to run through a transverse 
slit one inch from the top of the other ruler. The first ruler is held 
close to the foot, which is placed in a vertical position, and the other 
stick is held parallel to the first stick by an assistant at the head and 
the tape drawn until it is taut. When not in use the tape-measure is 
wound around the sticks. Next measure the circumference of the 
head and shoulders. Should there be shortening of a limb, or atrophy, 
as in infantile paralysis, full measurements of both limbs are to be 
made, i^g/zf -handed adults can commonly be told by the fact that the 
left hand is more apt to show the presence of scars and other signs of 
traumatic injury. Note the development of the skeleton, also any 
deformities and peculiarities, such as rickets, pigeon-breast, Pott's 
disease, etc. 

Estimate the weight and observe particularly the state of nutrition 
of the body; if emaciation be present, note whether it is due to defi- 
ciency in fat (panniculus adiposus), to muscular atrophy, or to a 
combination of both. This can usually be readily determined by pick- 
ing up a fold of skin over a muscle and rolling it between the thumb 
and fingers. One may practise this on himself, noting the differences 
in thickness found in the front, the back, and the sides of the neck. 

Post-mortem lividity, or hypostatic congestion, produces a bluish- 
red discoloration of the skin in the dependent parts of the body. This 
condition may resemble a bruise made during life, but the discolora- 
tion in post-mortem lividity disappears on pressure while that due to 
a bruise does not. Ante-mortem bruises and post-mortem lividity may 
also be differentiated by incising them. From a patch of post-mortem 
lividity blood will flow quite freely, because the vessels in the dependent 
parts are engorged with blood, while from a bruise there is little or no 
oozing, as the original hemorrhage is circumscribed and the discolora- 
tion is due mainly to staining of the tissues and not to the presence of 
blood. If the part be washed with running water, blood will appear 
again and again in hypostatic congestion. Should the two conditions 

1 If a tape-measure of this length is not at hand, forty-two inches of double 
inelastic tape may be sewed together and this attached to a measure of the ordinary 
length. 



48 POST-MORTEM EXAMINATIONS 

be combined, it is well to free the area from the hypostatic congestion 
before describing the bruise. Thus, if the lesion be situated on the 
back, it is well to let the body rest on the stomach for a time. As a rule, 
the more fluid the blood, as in cases of death from suffocation, the acute 
infectious fevers, poisoning by hydrocyanic acid, etc., the more marked 
will be the post-mortem lividity. In the latter case, as well as in poi- 
soning by illuminating gas, the lividity may be of a characteristic rose- 
red color. 

It is important to distinguish between post-mortem lividity and 
the greenish discoloration of commencing decomposition, usually first 
seen over the abdomen. The greenish color is due to the precipitation 
of the iron of the haemoglobin by the hydrogen sulphid arising from 
the decomposition of the tissues under the influence of bacteria. In 
one of my cases such discoloration was mistaken for a bruise, and 
serious allegations based upon this error were made against the hus- 
band of the deceased. 

Bodies which have been kept for a long time (or a shorter time 
under unfavorable conditions) after death, especially during cold 
weather, present another form of cadaveric lividity which is charac- 
terized by a uniform reddish tint. This is caused by the diffusion of 
haemoglobin from the blood-vessels into the surrounding tissues (im- 
bibition). This form of lividity is most conspicuous along the course 
of the superficial veins and is not affected by pressure. 

Much discussion has arisen in regard to the means at our command 
for distinguishing wounds made before and after death, and which is 
the fatal wound in case there are more than one injury. On these and 
similar questions I have heard experts testify in court in a manner 
utterly unsupported by the facts of the case. Great caution should, 
therefore, be used in the expression of dogmatic statements in regard 
to such findings. 

Post-mortem rigidity commences in the muscles of the jaw and 
spreads downward, disappearing in the same order. In ordinary cases 
it begins about two hours after death, is complete in from seven to 
nine hours, and ends in three or four days. The stronger the indi- 
vidual and the shorter the duration of the fatal disease, the more 
prompt and marked will be the rigidity. The bodies of soldiers killed 
by being shot in battle after forced marches sometimes retain the posi- 
tion they occupied when they were hit, in certain instances even re- 
maining erect when standing. Rigidity often sets in very early in 



EXAMINATION OF THE EXTERIOR OF THE BODY 4 q 

those who die suddenly, as while reading or while at table. It is very 
marked, especially in the abdominal muscles, after death from cholera. 
The body of one who has just died from tetanus or strychnine poison- 
ing may lie supported only by the head and heels, or when placed 
upright may stand erect with little or no support. It should be remem- 
bered that in the preparation of the body by the undertaker the rigidity 
may have been overcome by force ; this is especially true of the elbows. 
Be careful, on the other hand, not to be deceived by previously existing 
ankylosis. 

Rigidity disappears more quickly in cachectic subjects, and is some- 
times almost entirely absent in heat-stroke. It may be overcome by 
the use of hot applications, but when it has once disappeared it seldom 
returns and is never again so pronounced as at first. Strychnine and 
other spinal poisons, as veratrum viride, and suffocation cause long- 
continued post-mortem rigidity. In one of my cases of strychnine poi- 
soning rigor mortis was present on disinterment twenty-four days after 
death. 

The color of the skin varies : it rarely possesses the rosy hue of 
health, but is rather of a light grayish white, most conspicuous in cases 
of poisoning by the chlorate of potassium. The skin on those parts 
which have been exposed to the sun is generally more or less tanned. 
The color in jaundice varies from the faintest tinge of yellow to a 
dark yellowish brown. The pallor due to loss of blood is often so 
marked as to suggest the possibility of internal hemorrhage, as from 
the rupture of an aneurism or of the sac in extra-uterine pregnancy. 
The cachexias of cancer, argyria, etc., are at times peculiarly con- 
spicuous in the dead body. The color of the integument in argyria is 
similar to that of living persons when they are exposed to the light 
produced by burning a solution of salt and alcohol in a dark room. 
The patches of bronzed skin, alternating with affected areas, seen in 
Addison's disease, may be scattered over the entire body, but are espe- 
cially well marked on the abdomen; they are also sometimes found 
upon the mucous membrane of the mouth. This bronzing may occur 
when the suprarenal bodies are still apparently normal. Moles, tattoo- 
marks, and certain cutaneous diseases, such as vitiligo, leucoderma, 
etc., cause discolorations of the integument peculiar to themselves. 
Redness of the skin may be due to the wearing of red underclothes. 

Parchment-like spots are often seen on the body where the epi- 
dermis has been robbed of its protecting epithelium. Such areas are 

4 



5 POST-MORTEM EXAMINATIONS 

due to drying of the part, and if produced during life there will usually 
be found some ecchymotic spots surrounding them. When seen around 
the mouth, they suggest the possibility of the previous introduction of 
such agents as strong acids (including carbolic) and alkalies. The 
drawn-up and wrinkled appearance of the skin known as " goose- 
flesh," or cutis anserina, is especially conspicuous after drowning. The 
scrotum here is markedly contracted and the testicles are drawn up. 

Note the presence of bed-sores, blisters (remember that blisters 
found on dead bodies are sometimes due to carelessness in the use of 
hot-water bags or bottles during the final illness), the marks of saline 
injections (dermatolysis), hypodermatic injections, and cupping. In 
a recent case posted by me the trocar had penetrated the lung and given 
rise to abscesses, which resulted in the death of the patient. In another 
case the exploratory needle used in searching for a right-sided pleural 
fluid penetrated the liver and gave rise to a fatal hemorrhage. Scars 
made by the hypodermic needle in persons addicted to the use of mor- 
phine are usually found on the arms and thighs, — i.e., in those situa- 
tions which are hidden by the clothes and yet are easily accessible to 
the individual. Small abscesses containing pus are often present in 
these cases. Hypodermic injections by physicians shortly before death 
are usually made over the deltoid muscles or the breast, this region 
being selected owing to the quickness with which the drug is here 
absorbed into the general circulation. The punctures may be sur- 
rounded by an elevated white or reddish area similar to that produced 
by the application of cups. 

Many signs of inflammation, especially of the mucous membranes, 
disappear soon after death. Enlargement of the superficial lymph 
glands (especially in the inguinal region as found in syphilis) should 
be noted. Even an extreme eruption of measles may disappear after 
death. If it is desired to study such lesions, or others which disappear 
post mortem, it will be necessary to mark their location during life 
with a dermographic or anilin pencil or by the use of silver nitrate. 

General or local oedema is noted, especially as to its extent and the 
character of the pitting on pressure. 

Ask if the eyes and mouth were open or closed when death oc- 
curred, and find out if the expression was peaceful or the countenance 
distorted. Note the color of the eyes. Look at the pupils, cornese, and 
conjunctivae, taking care to close the eyes after they have been exam- 
ined. Jaundice, especially in the negro, may best be seen in the con- 



EXAMINATION OF THE EXTERIOR OF THE BODY y 

junctivae. Examine the eyes for arcus senilis. The size of the pupils 
is best estimated in millimetres. In death from chloroform the pupils 
may remain enlarged; in opium poisoning the pupils often expand 
shortly before or after death. 

Note the color, length, quality, amount, distribution, etc., of the 
hair on various parts of the body, as the scalp, eyebrows, eyelashes, 
axillae, pubes, breasts in the male, etc. Pass your fingers through the 
hair, if it be at all thick, to discover injuries, tumors, etc., which it 
may conceal. Should these be discovered the hair may be parted so 
as to examine them more carefully, or it may be cut or partly shaved 
off; in injuries to the head, however, it will usually be found that this 
has already been done by the surgeon. The region of the neck should 
be carefully inspected for finger markings, scratches, rope markings, 
etc. The neck should be rotated so as to see if a fracture or a disloca- 
tion exists. 

The condition of the teeth and gums should next be determined. 
Hutchinson's teeth may be discovered. 

Look for linese albicantes, and always examine the breasts of 
women and note the presence of fluid or tumors. The character of the 
fluid in abortion is especially to be noted. Supernumerary nipples are 
not uncommon, and a well-formed breast with its nipple may be found 
in the axilla. 

In cases of death by electricity the points of entrance and exit of 
the current ought to be carefully sought for, and the shoes should be 
examined for the burns which are usually seen near the nails in the 
heels. 

Examine the skin for any abnormal marks, such as eruptions, scars, 
wounds, bruises, blood, dirt, etc. ; it is possible for a wagon or even a 
street-car to pass over the body without leaving any trace on the skin 
other than a brush-burn. 

Discharges from the ear, nose, mouth, vagina, urethra, or rectum 
should not be overlooked, and foreign bodies found in any of these 
orifices should be noted. 1 See if the secretion is fluid or dried, watery 
or purulent. Xote its color and odor. In rape any vaginal secretion 
should be examined microscopically for spermatozoa and Gonococci 
and the condition of the hymen noted. 



1 The creation of the office of coroner in England was due to the pouring of molten 
lead into the ear with homicidal intent. 



52 



POST-MORTEM EXAMINATIONS 



Do not neglect the examination of the back, which may readily 
be made by turning the body on one side. The anal region should be 
inspected for fissures, fistulse, eruptions, etc. The part is often dis- 
torted by the previous introduction of cotton by those who have had 
charge of the body. 

Examine for scars on the genitalia (when on the glans penis or 
prepuce they are usually of syphilitic origin) and on the mucous mem- 
brane of the mouth. Look for herniae, hydrocele, etc., and for external 
parasites, such as pediculi. Lice upon the body or head are often asso- 
ciated with alcoholism ; pediculi crack with a loud noise when thrown 
into a hot fire. These annoying parasites may be quickly and effect- 
ually disposed of by saturating a towel with chloroform 2 or kerosene 
and placing it upon the head for a few moments preparatory to re- 
moving the brain. 

See if the penis is erected ; it is often found in this condition after 
death by hanging. Injuries to the spinal cord may give rise to similar 
conditions. I have often seen after drowning erection of the penis due 
to the formation and collection of gases from decomposition in the 
loose areolar tissue. Note if the prepuce is moist from the escape of 
urine; if the discharge is purulent, search for the Gonococcus. 

Observe the condition of the extremities, especially as regards the 
presence of injuries, dislocations or fractures, deformities, gouty de- 
posits, etc., and the lobes of the ear for tophi. Examine the tibiae for 
thickening of its periosteum, etc. 

After the body has been carefully inspected it should be examined 
by palpation and percussion, but in handling it care should be taken 
not to disturb the relations of the contained viscera. Consolidation of 
the lungs, enlargement of the spleen, liver, etc., may be revealed by 
palpation or percussion even when the organs are not in their normal 
positions. 

The odors of many drugs, such as carbolic acid, oil of bitter al- 
monds, etc., may be detected from the mouth. The odor of alcoholic 
beverages can best be noted from the brain. Certain diseases, as small- 
pox, have characteristic odors. In one of my cases of poisoning by 
ammonium hydrate a rod dipped in hydrochloric acid when held near 
the mouth gave off fumes of ammonium chlorid. 

1 Formalin may be used if it can be applied several hours previous to the post- 
mortem, but its fumes are so irritating as to forbid its application when the autopsy 
is to be made immediately afterwards. 



EXAMINATION OF THE EXTERIOR OF THE BODY 53 

In a male infant observe whether the testicles have descended. In 
a female child see if the ovary lies in the canal of Nuck. Examine the 
regions where hernia is apt to occur. In a new-born babe look for 
vernix caseosa and pay special attention to the umbilicus and its 
vessels. 

An entire chapter might easily be written on the significance and 
value of scars induced by various means. Those made by the surgeon 
are often from their location self-explanatory. 1 It would, however, 
certainly facilitate matters, in this age of numerous hospitals and fre- 
quent operations, if the absence of organs removed by operation were 
indicated by some method which would be generally understood. Thus, 
the first letter of the Latin name of the part excised followed by the 
sign minus might be tattooed on the skin near the initial incision ; e.g., 
A — would show that the appendix had been removed, R — that 
nephrectomy had been performed, etc. The presence of scars may lead 
the obducent to think of herpes zoster, cupping, smallpox, chicken-pox, 
various skin diseases, as acne and syphilis, explosions, setons, certain 
occupations, etc. 

1 The writer once desired to secure for a friend some fresh testicular tissue, and 
hurried to a recent suicide for the purpose of obtaining the testes. Finding scars 
on the scrotum, but no testicles, it was learned on investigation that these organs 
had been removed several years previously, and the young man had committed 
suicide because for this reason he was unable to marry. 



CHAPTER VI 

TECHNIC OF EXPOSING THE ABDOMINAL CAVITY AND THE TOPO- 
GRAPHICAL EXAMINATION OF THE PARTS CONTAINED THEREIN 

After the completion of the preliminary examination of the exte- 
rior of the body, having placed all necessary instruments in order upon 
a board or tray, 1 and having plenty of basins and water, with sponges 
and towels, the operative part of the autopsy may be begun. 

The operator should stand so that when facing the body the in- 
cisions from the head towards the feet can be made with the greatest 
ease. Thus, it is best for right-handed operators to stand on the right 
side of the supine subject. The body should be drawn well to the side 
of the table nearest the operator, the head resting at the top of the 
table and the shoulders supported by a block. 

With the knife held in the manner previously described (page 38), 
as nearly horizontal as possible, a clean incision (Fig. 43) should be 
made by a single sweep from the interclavicular notch (A) to the 
symphysis pubis (B), passing to the left of the umbilicus (C) in order 
to avoid the round ligament and any vessels going to and from the 
navel, care being taken not to penetrate the abdominal cavity and thus 
injure the contained viscera, or extend the incision to the external 
genitalia (Figs. 46 and 47). On the chest this primary incision goes 
down to the bone, whereas on the abdomen it penetrates only to the 
muscle-sheath. In Europe the initial incision is usually made at the 
middle of the chin, — i.e., starting at the symphysis menti and ending 
at the symphysis pubis; for there, as a rule, only those who die in 
the hospitals reach the post-mortem table, autopsies being seldom 
performed on the bodies of persons belonging to the upper classes, 
who would naturally object to the disfigurement entailed by this 
method. In this country the longer incision should be used only when 
great haste is necessary, as in cases of contagious diseases, such as 
diphtheria, or when the body is not to be seen again by relatives or 
friends. 



1 A towel may be laid over the external genital organs and the upper parts of the 
thighs, upon which the instruments to be used in the performance of the autopsy are 
placed with their handles towards the obducent. 
54 







Fig. 46.— Method of making the initial incision over the sternum, as seen from above. 




Fig. 47.— The same incision as in Fig. 46 somewhat extended, as seen from the side. 




Fig. 48. — Method of raising flap on right side so as to expose sternum and ribs, as seen from above. 




Fig. 49. — Same incision as in Fig. 48 somewhat extended, seen from the side. 



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TECHNIC OF EXPOSING THE ABDOMINAL CAVITY r- 

The initial incision over the thorax is now carried down to the 
sternum, and the layers of skin, fascia, and muscles of the right side 
are quickly dissected away close to the ribs, freely exposing* the costo- 
cartilaginous articulation and some three inches of the sternal end of 
the clavicle. To do this the attachments of the soft tissues are made 
tense by drawing them from the median line (Figs. 48 and 49), 
making long sweeping incisions downward and laterally with the large 
section-knife. The left side may next be similarly treated, though in 
practice this is more frequently done after the abdominal incision has 
been completed. 

Should a pneumothorax have been diagnosed during life, the tho- 
racic pocket made by elevating the skin flap on the side of the pneumo- 
thorax is filled with water and a puncture made at the bottom through 
the costal pleura between the sixth and seventh intercostal spaces at 
the axillary line. If a pneumothorax be present, bubbles of air will 
escape. If the head be lowered and the supply of water be sufficient, 
this will finally escape from the mouth. It should be remembered that 
a cavity in the lung opened by the initial incision would give the same 
result as that found in a pneumothorax. 

A note is now made as to the situation and character of any blood 
which may escape. The character of the fat (panniculus adiposus) 
is considered, and its thickness noted at the nipple-line below the 
xiphoid and again three inches below the navel. In atrophy the color 
of the fat becomes darker, changing to orange or reddish yellow. The 
tissues here are often cedematous, as in general dropsy or erysipelas. 
As a rule, the older the individual the darker in color is the fat, varying 
from straw-color in children to dark yellow later on in life. Different 
species of animals have different colored fat, depending upon the differ- 
ence in its chemical composition. The mammary glands may now be 
examined from behind, and, if desired, the glands of the axillae may 
be exposed by continuing the dissection of the pectoral muscles from 
beneath. 

The muscles here included are those of the neck, chest, and abdo- 
men. Both a transverse and a longitudinal section are necessary to a 
complete study, and the following general characteristics should be 
observed in all muscles. 

(a) Size. — The external examination has already noted any 
marked changes in bulk. The muscles may be atrophic or hyper- 
trophic. 



5 6 POST-MORTEM EXAMINATIONS 

(b) Color. — Normally this is a bright red, but in anaemia it be- 
comes paler, at times a grayish red. In typhoid fever a dark red color 
is often found; at other times in typhoid, as well as in diseases where 
the muscles have long been inactive, a grayish translucent appearance 
is observed, — waxy degeneration. In general it may be said that the 
color and consistence of the muscles bear a distinct relation to each 
other : pale muscles are usually soft, while the darker muscles are more 
firm. The muscles are dry when much fluid has been carried off by 
the alimentary canal, as in typhus and cholera, and moist in disturb- 
ances of the circulation. 

(c) Cut Surface. — The usual moist glistening appearance may be 
lost in typhoid, while in ©edematous conditions considerable fluid may 
ooze out. 

These general characteristics having been observed, the pathologi- 
cal conditions to which these muscles are subject are not liable to escape 
detection. The important pathological conditions are : 

i. Hemorrhages. — These may result from trauma, wet cups, etc. 
A special form of bleeding into the rectus may occur in typhoid fever, 
— " haematoma recti abdominis." 

2. Inflammations. — Under these are included : 

(a) Acute Interstitial Myositis. — This is suppurative, and may be 
primary, from trauma, or secondary, in the muscles of the chest, to 
pleural affections, or, in the muscles of the abdomen, to pelvic suppu- 
ration. This inflammation does not, as a rule, produce true abscesses, 
but infiltrates the muscle and separates the fibres, which undergo a 
fatty or hyaline degeneration. 

(b) Chronic Interstitial Myositis. — The interstitial connective tis- 
sue is increased so that at times it is visible to the naked eye, the mus- 
cle-fibres are atrophied, the color becomes a grayish red, and the 
muscles feel hard. This condition is generally associated with dis- 
eased states of the neighboring parts, — e.g., affections of the ribs, 
pleurae, cervical glands, etc. 

(c) Parenchymatous Myositis. — The muscle is paler than normal. 
Microscopical examination is necessary in order to determine whether 
the change is cloudy swelling, hyaline, or fatty degeneration. 

3. Parasites. — The most important parasite is the Trichina spiralis, 
which, especially when calcified, may be seen with the naked eye. 
These organisms are found most frequently in the muscles of the neck 
and in the intercostals near the attachment of the diaphragm. In the 



TECHNIC OF EXPOSING THE ABDOMINAL CAVITY 57 

muscle itself the site of election is close to the portion where the tendon 
unites with the muscle proper. In old cases the calcified capsules are 
easily recognized as small, white, oval bodies, which when present in 
large numbers look like grains of white sand. In order to see the para- 
site the capsule must be dissolved with hydrochloric acid. In earlier 
stages the animal is less readily seen, and its detection is made easier 
by pressing a teased portion of muscle between two glass slides and 
observing it by transmitted light. Non-encapsulated trichinae cannot 
readily be seen without the aid of the microscope. 

A series of light incisions over the abdominal cut is made between 
the umbilicus and the xiphoid cartilage until a small portion of the 
peritoneum is exposed. 1 The peritoneum should then be carefully 
opened and a note made of the presence or absence of gas or fluid. 

If it be desired to determine the presence and the character of gas 
in the abdominal cavity, the incision is made down to the peritoneum, 
either two inches above or the same distance below the umbilicus, 
and the abdominal walls are elevated with the fingers or a tenaculum 
so as to form a pouch, into which water is poured. A test-tube is then 
filled with water and inverted, and a small incision is made through 
the peritoneum under the mouth of the test-tube so as to allow the 
escape of gas into it. The test-tube is then tightly closed by pressing 
a thumb or finger up against its mouth, and placed in a shallow dish 
containing sufficient water to seal the open end of the tube. If a 
lighted match is held close to the point where a knife is pushed into 
the chest, any gas escaping deflects the flame. It should be remembered 
that certain gas-forming organisms may be the cause of the collection 
of gas in the serous cavities. The recent discovery of hitherto un- 
known elements in the air makes the study of aggregation of gases 
here an extremely interesting one. If the gas has an acid odor, a 
perforation in the wall of the stomach is to be suspected. 

If fluid be present, as in ascites, just enough should be removed 
tc facilitate the determination of the height of the diaphragm. The 
height and location of this muscle may be determined by introducing 
the hand, palm upward, or a steel sound into the abdominal cavity and 
following the under surface of the diaphragm as far as possible. The 



1 Should a bacteriological examination be required, a portion of the peritoneum is 
seared with a hot knife before opening it and the abdominal cavity is incised with a 
sterilized knife. 



5 8 POST-MORTEM EXAMINATIONS 

tips of the fingers or the end of the sound should be carried to the point 
of least resistance and this spot sought for with the other hand from 
without. The vault of the diaphragm extends to the fifth rib on the 
left side and to the fourth rib or fourth interspace on the right. Both 
sides are measured in the line of junction of the ribs with the costal 
cartilages. The greater height on the right is due to the liver, which 
forces the diaphragm upward. Increase in the abdominal contents, 
as by tumors, pregnancy, hypertrophy of the spleen, etc., pushes the 
diaphragm upward. On the right side by hypertrophy of the liver 
it may reach the level of the second rib. Increase in the thoracic 
contents naturally presses the diaphragm downward. Along with the 
depression is a sense of fluctuation in cases of hydrothorax. The posi- 
tion of the diaphragm in a new-born child helps to determine whether 
or not it has breathed. Before respiration has occurred the summit 
is found on a level with the fourth rib on the right side, and on a level 
with the fifth rib or the fourth intercostal space on the left. After 
full expansion of the lungs has taken place, the summit is found at 
the fifth or sixth rib on the right, and at the sixth rib on the left 
(Orth). 

The opening may now be somewhat enlarged and additional fluid 
removed with a syringe, cup, or large pipette, measured, and its char- 
acter noted. The remaining portion may afterwards be removed from 
the various folds and pouches in the peritoneum by a sponge or small 
cup. The amount of fluid normally present is very small, not usually 
exceeding a teaspoonful; it may be lemon-yellow, red, or brown; 
icteroid or milky; watery, thick, gruel-like or even semisolid. The 
removal of liquid at this stage of the operation prevents its admixture 
with blood, as from an accidental incision made in the liver while 
cutting the costal cartilages, or with other fluids of the body, such 
as those from the pericardium, the pleura, the bladder, or various 
portions of the intestinal tract. 

In cases of increased amount of fluid it is of importance to distin- 
guish between a serous transudate and an inflammatory exudate. 
When large amounts of pus and fibrin are present, the differentiation 
is easy, as a transudate contains neither. Difficulty arises when a clear 
watery fluid is found in which minute flocculi are seen, as these may be 
either small flakes of fibrin and pus-cells or small collections of washed- 
off endothelial cells. The differential points may be tabulated as fol- 
lows : 



TECHNIC OF EXPOSING THE ABDOMINAL CAVITY $g 

Transudate. Exudate. 

Fluid clear and watery. Fluid thick and ropy. 

Alkaline reaction. Aci<4 reaction. 

Flocculi are thin, veil-like, and of a trans- Flocculi are thick, opaque, and of a 

parent gray color. grayish- white color. 

Specific gravity usually below 1016. Specific gravity usually over 1016. 

Albumin usually below three per cent. Albumin usually above three per cent. 

Microscope shows the flocculi to consist Microscope shows the flocculi to consist 

of flat cells with large nuclei and lym- of fine threads and polynuclear leuco- 

phocytes. cytes, the nuclei of which appear more 

distinctly on the addition of acetic acid. 

Milky exudates are of two kinds, fatty and chylous. The former 
excretion has been found in connection with peritoneal and mesenteric 
cancer, and is recognized by the fat-globules seen on microscopical 
examination. Mild cases may be due to the fact that the patient was 
on a milk diet and had a lipsemia, a dyscrasia also found in diabetes 
(Osier). A chylous exudate results from the perforation of the tho- 
racic duct or the receptaculum chyli. 

Suppurative exudates are thick, yellowish, and contain much fibrin, 
w r hich is deposited on the peritoneum and bowel in layers. The odor, 
which is peculiarly nauseating, is due to the Bacillus coli communis 
or to fecal masses, as in perforation; this process is usually an acute 
one. 

A hemorrhagic exudate or fluid may be non-inflammatory, as from 
trauma (rupture of the liver or spleen or extra-uterine pregnancy) 
and from some cases of cirrhosis of the liver, or inflammatory, as in 
cancerous and tuberculous peritonitis. Pure bile, most frequently 
mixed with blood, may be found in the abdominal cavity from injury 
of the gall-bladder or the bile-ducts. 

A single finger is now introduced into the opening previously made 
in the abdominal cavity, the flap of skin is elevated, and the incision 
is somewhat lengthened. Then the index and middle fingers of the 
left hand, held V-shaped (Fig. 50), palm upward, are thrust under 
the abdominal wall in order to raise it above the intestines so as to 
prevent injury to them in the subsequent incision, the fingers acting 
as a director while the cut is continued to the pubes. If there be much 
meteorism, the index-finger of the left hand can be introduced and 
held against the parietal peritoneum. If scissors be used, the lower 
blade may be guarded by the fingers of the left hand when the cut 
is made. Another method is to make strong traction on the right 



6o POST-MORTEM EXAMINATIONS 

abdominal flap in the direction of the operator's head and when the 
part is well elevated above the intestine cut from without inward. The 
cutting should preferably be done from within outward, great care 
being taken not to puncture or injure any of the abdominal viscera. 
It is well to break up adhesions with the index-finger. Should the 
intestinal tube be accidentally opened, it is best to stop at once and 
tie both above and below the opening in order to prevent the escape 
of the contents of the bowel into the peritoneal cavity. 

If it be desirable to enlarge the opening in the abdominal wall 
(Fig. 43), a second incision (D E) may be made, at right angles to 
the first one and about three inches above the umbilicus, or the rec- 
tus muscles on one or both sides of the body may be divided subcuta- 
neously a little above Poupart's ligament (F and G). Should there 
be a penetrating wound of the abdomen, as from a dagger or a pre- 
vious cceliotomy, the abdominal incision may be changed at will (Figs. 
44 and 45). When the contents of the stomach are found in the peri- 
toneal cavity, care must be taken to determine whether their escape 
was due to post-mortem digestion, to erosion of the coats of the 
stomach, or to perforation from a gastric ulcer. In the first case the 
gastric contents are found in the immediate neighborhood of the per- 
foration and the rent is large; while in the latter cases the opening 
is small and circular, the ingesta are usually widely distributed 
throughout the abdominal cavity, and signs of peritonitis are present. 

Undigested food in the peritoneal cavity points to its exit from the 
stomach; when digested food or faeces are present, the seat of injury 
is the bowel or duodenum, and, if the latter, the material is usually 
stained with bile. The presence of such material, when not escaping 
through a traumatic opening, is usually due to the perforation of a 
round ulcer, to autodigestion, or to putrefaction. Autodigestion is 
especially frequent in cachectic children. In perforation from this 
cause the loss of tissue is greater and the opening more irregular than 
in one caused by round ulcer, the walls are soft and slimy, blood and 
peritonitis are absent, and the intestines have a blistered appearance 
due to the corrosive action of the gastric juice. From the fact that 
the autopsy is usually performed some time after death, the appear- 
ances presented by a round ulcer are slightly different from those seen 
at an operation during life, for the serous wall of a gastric ulcer may 
undergo post-mortem digestion and its true appearance be thus altered. 
Foreign bodies, which may be calcified, are sometimes found free in 



EXAMINATION OF THE ABDOMINAL CAVITY 6j 

the abdominal cavity; they are derived from torn-ofT appendices epi- 
ploicse or polypoid tumors. Intestinal worms may escape into the 
peritoneal cavity through openings produced by the perforation of 
ulcers. Surgical instruments and appliances may be discovered in the 
abdomen after the performance of operations. 

The abdominal cavity now being thoroughly exposed, the most 
striking abnormalities contained therein are to be noted. Transposi- 
tion of the viscera would at once be noticed. The most marked dis- 
placements of abdominal organs which I have ever seen have been in 
Pott's disease and diaphragmatic herniae. 

The situation of the omentum usually comes first under observa- 
tion. Normally it is non-adherent to the intestines except at its point 
of attachment; in purulent peritonitis it may be markedly adherent to 
the peritoneum covering the intestinal tract, creamy or plastic lymph 
appearing in streaks throughout its structure. The omentum may 
form a part of all varieties of hernia found in the abdomen; it may 
he present alone in the hernial sac, or the intestines may become stran- 
gulated by passing through an opening in it. The amount of fat 
deposited within its layers varies considerably, being in some cases 
practically absent and in others as much as half an inch in thickness. 
During health the omentum is rich in fat, which disappears early and 
rapidly in emaciation. By atrophy of the connective tissue, openings, 
some of which may be of large size, are produced. Normally the 
layers are readily separable, and when spread out form a beautiful 
picture of a delicate, thin, transparent membrane, with irregular de- 
posits of fat, and showing the blood-vessels partly filled with blood. 
It is a favorite seat of fat necrosis, tuberculosis, and generalized cancer; 
in the last two conditions it may be so contracted upon the transverse 
colon as to be hardly visible and only separable therefrom with the 
greatest care. Enlarged glands, encysted parasites, infarcts, super- 
numerary spleens, etc., may be found. It may, even when normal, be 
rolled upon itself, forming an integral part of the transverse colon or 
the greater curvature of the stomach. 

The transverse colon may be U-shaped, extending to the bladder; 
it may or may not drag down the stomach. In some cases it forms 
peculiar S-shaped curves; in others the hepatic and splenic flexures 
may be markedly deficient. 

Note if the gall-bladder extends below the liver, and if so to what 
extent. Follow with the hand the upper surface, first of the right lobe 



62 POST-MORTEM EXAMINATIONS 

and then of the left, in order to determine their extent, noting the 
height and the distance to which they extend below the ribs. The tips 
of the right and left lobes of a large liver sometimes almost meet at 
the vertebral column. The left lobe may extend downward like a 
beaver's tail, and from tight lacing the whole organ may be divided 
into an upper and a lower portion by bands of connective tissue con- 
taining the biliary vessels and a few liver-cells. Extra lobes are very 
common; some of them even take the form of supernumerary livers. 
This condition may be congenital, but is more frequently due to syph- 
ilis. In one of my syphilitic cases the liver was made up of more than 
thirty lobes, in shape resembling a bunch of flattened and distorted 
hydatid cysts. The liver should next be slightly raised, the pylorus 
examined, and the tips of the fingers used to determine the presence 
of calculi in the bile-ducts and gall-bladder. 

The stomach is subject to marked changes in size and in situation, 
as from hour-glass contracture, tumors, ulcerations, etc. In the babe 
its situation is nearly vertical. 

All the openings in which herniae are apt to occur are next to be 
examined, the order of frequency being inguinal hernia in the male 
and femoral and umbilical herniae in the female. Other forms of 
hernia are those through the canal of Nuck, the obturator foramen, or 
the sciatic notch ; into the various fossae about the caecum or the fossa 
jejunalis ; into new fossae formed by bands of adhesion, as from extra- 
uterine pregnancy; from solutions of continuity in the mesentery;, 
crural ; diaphragmatic, which is often congenital, but may be due to- 
traumatism; between the rectus muscles and through Petit's triangle; 
after operations, especially those on the appendix, etc. 

Volvulus and invagination are not infrequently seen. True in- 
vagination is distinguished from a form which often occurs in children 
just previous to death, by the presence of adhesions; in the latter case 
these are produced in the agonal period and are multiple, sometimes 
as many as fifteen or twenty being found. There is a peculiar form 
of invagination in which the ileocaecal valve draws the ileum down 
into the caput coli ; this condition when extreme may even cause the 
ileocaecal valve to appear at the anus. 

The serous covering of the intestines should be minutely inspected,, 
as the play of colors is very varied and the information gained from 
this examination is often of great importance. In thrombosis of the 
mesenteric vessels the gut may be gangrenous for ten feet or more. 



EXAMINATION OF THE ABDOMINAL CAVITY 63 

Miliary tubercles are found opposite tuberculous ulcers and extend 
along the lymphatics; they are also seen on all the other portions of 
the peritoneum, often being wide-spread in tuberculous peritonitis. 
Small yellowish, creamy collections of lymph, with dilated lymphatics, 
are seen if death occurred several hours after eating ; these are physio- 
logical and not pathological products, but I have known them to be 
mistaken for miliary tubercles and even for carcinomatous growths. 
The presence of typhoid ulcers may be recognized by a congested area 
running along the length of the intestine. The location of the vermi- 
form appendix should always be noted, and Virchow's dictum (pub- 
lished in 1875, though long put in practice) should be remembered : 
" At least in every case of inflammation of the peritoneum the appen- 
dix is to be carefully examined." In the female an examination 
should be made of the uterus and its adnexa. The mesenteric glands, 
especially those near the ileocecal valves, are to be carefully looked 
at; they are greatly enlarged in typhoid fever, where they sometimes 
undergo suppuration, and in children dying from inanition, where they 
appear as red nodes, often running together into conglomerate masses. 

Cotton which has been inserted in the rectum or vagina by the 
nurse or undertaker to prevent the escape of fecal or other matter 
may be mistaken for a foreign body and may possibly have caused 
displacement of neighboring parts. When no extensive pathological 
lesions exist, the situation of the pancreas may readily be determined 
by remembering its connection with the concavity of the duodenum. 

During this superficial examination of the abdominal cavity any 
needful departure from the ordinary routine may be planned. Thus, 
in a case of cancer of the head of the pancreas it may be advisable later 
on to remove this organ along with the stomach, the duodenum, or 
even the liver. Again, in the case of a child or when there is not time 
for a careful dissection, all the organs of the abdominal cavity may be 
removed en masse. 

To repeat, the relative positions of all the tissues should be ob- 
served and any departure from the normal noted, and a careful search 
made for foreign growths, anomalies, etc., none of the parts being at 
this time removed from the body or their relations disturbed for fur- 
ther examination. 



CHAPTER VII 

TECHNIC OF EXPOSING THE THORACIC CAVITY AND THE EXAMINA- 
TION OF THE PARTS CONTAINED THEREIN 

After a superficial examination of the abdominal cavity (with- 
out the use of the knife) is complete, the thorax should be exposed to 
view in the following manner. The costal cartilages on the right side, 
from the second to the tenth, are cut through, one by one, from above 
downward, at a point a few millimetres to the sternal side of their 
attachments to the osseous portions of the ribs. For this purpose a 
heavy cartilage-knife is employed, which should be held as nearly par- 
allel to the chest surface as possible, so that as the blade cuts through 
one cartilage it strikes the next one, thus preventing injury to the 
organs beneath. Or the knife may be introduced in the intercostal 
space beneath the rib that is about to be cut, using the next lower rib 
as a fulcrum and cutting from within outward ( Fig. 51). Each lower 
rib is incised more and more towards the axillary line and away from 
the median line of the body, making the opening in the chest larger 
and larger as the incisions proceed down the chest. In cases where 
the cartilages are calcified it may be necessary to use a costotome or 
a saw for their division, in which event the ribs are cut outside the 
costochondral junction in order to allow more room for the subsequent 
manipulations. The second to the tenth ribs on the left side are now 
severed. 

The right clavicle is next separated from the sternum. As its 
head articulates with the sternum and the cartilage of the first rib, the 
clavicle is grasped with the left hand and the sternal end of the bone 
is moved to and fro, or an assistant can produce the same result by 
moving the whole arm. In this way the line of articulation is easily 
made out and permits the part to be disarticulated by cutting down- 
ward and slightly outward, until the first rib is reached (Fig. 52), 
thence continuing outward along the under border of the clavicle for 
at least two inches. The first rib, which is generally calcified, is next 
cut through with a knife from below and outward or from above and 
inward (Fig. 53). Or, the costotome may be employed for this pur- 
pose (Fig. 54). The next procedure is accomplished by making 
64 




Fig. 52. — Method of separating the sternoclavicular attachment. The articulation is dis- 
covered by steadying the sternum with the right hand and moving the clavicle in opposite 
directions with the left hand. Unless marked ankylosis exists, incision with the knife is easy 
after the discovery of the articulation. 




Fig. 53. — The incision through the first rib is here shown. The previous incision seen in 
Fig. 52 has been carried almost to the thumb, the clavicle elevated, and the incision made 
through the first rib. 




Fig. 54. — Method of incising the first rib and the sternoclavicular articulation with the costotome. 




Fig. 55.— All the ribs of the right side have been severed, the sternoclavicular attachment to the first 
rib remaining intact on the left side. The lower portion of the sternum is elevated and traction made on 
the diaphragm, which is cut as close as possible to the lower border of the sternum. 




Fig. 56. — The lower border of the sternum having been freed, the breastplate is elevated and pulled 
upward and towards the left. The left sternoclavicular attachment is thus easily discovered, and. is cut 
through, as well as the first rib. 




Fig. 57. — In this illustration the sternum is practically ready to be removed from the body. The knife is 
cutting any attachments which may not previously have been severed. 



TECHNIC OF EXPOSING THE THORACIC CAVITY 65 

traction on the breastplate upward and towards the right. Beginning 
below on the left side and keeping close to the bone, the tissues are cut 
through with short transverse cuts of the knife (Fig. 55). All of 
the lower attachments having been cut, the breastplate is now elevated 
and any uncut tissues of the mediastinum and of the right side are 
incised; the sternum is pulled towards the left; the sternoclavicular 
attachment on this side, having been made tense, is easily discovered, 
and this part along with the left clavicle is severed from below (Fig. 
56). The sternum is next severed, as seen in Fig. 57. The breast- 
plate, after its removal, is shown in Fig. 58. If an aneurism or tumor 
be found attached to the ribs or sternum, this point of attachment is 
preserved by sawing through the bone some distance away. In order to 
protect the hands of the operator from injury, the skin flaps are now 
wound around and beneath the exposed clavicle and ribs (Fig. 59). 

In the performance of the operation for the removal of the sternum 
great care is necessary in order to avoid cutting the innominate or 
internal mammary veins which lie beneath the clavicle and the upper 
part of the sternum. In Bavaria and Wiirtemberg, in order that these 
vessels may not be injured, the regulations for the performance of 
medicolegal autopsies direct that, after cutting the cartilages from the 
second to the tenth in the manner described, the soft parts attached to 
the lower border of the sternum be divided, the mediastinal tissues 
separated, the lower end of the sternum strongly elevated, and the 
sternoclavicular connection and the first rib cut from the under side, or 
the sternum may be sawn through below the attachment of the first rib, 
leaving it and the sternoclavicular articulation intact. I do not approve 
of the method often used after cutting the ribs, of breaking the ster- 
num by turning it backward just below the clavicular attachment. 
Though it avoids injuring the veins, it leaves an ugly place from which 
to receive scratches and does not give the same amount of room for 
the examination of the thoracic cavity and neck. Some careless op- 
erators do not even remove the bone, but while still attached turn it 
back over the face. 

The examination of the sternum and ribs may now be undertaken. 
Their shape is often altered, as in Pott's disease, pigeon-breast, emphy- 
sema, perforated sternum, etc. Tuberculous caries of the sternum, 
often secondary to caseation of the mediastinal lymph glands, may be 
present, or an aneurism may cause pressure atrophy (erosion) or even 
perforation of this bone. A form of internal pressure atrophy is seen 

5 



66 POST-MORTEM EXAMINATIONS 

in the shoemaker who holds the shoe against his breast. Fracture is 
not common, but may occur between the second and third costal carti- 
lages, — i.e. j near the junction of the manubrium with the gladiolus. 
The ensiform appendix of the sternum is sometimes curled upward 
and outward, like a hook, in cases of hypertrophy or of tumor of the 
liver. When this condition is present in atrophic cirrhosis of the liver, 
it indicates a previous enlargement of that organ (Suchard). The 
marrow of the sternum, which may be exposed by a longitudinal sec- 
tion of the bone, is normally a slightly reddish, lymphoid bone-marrow, 
and may present the changes characteristic of leukaemia, anaemia, 
tuberculosis, etc. The ribs may show evidence of rhachitis in the pres- 
ence of the rhachitic rosary, in which case a section of the rounded 
enlargements, especially where the cartilage joins the bones, will show 
the changes peculiar to rickets. In old persons the entire cartilage may 
be calcified or even ossified. The central substance of the ribs some- 
times undergoes atrophy and absorption, leaving a large canal filled 
with blood. The cartilage may contain cystic cavities. 

The sternoclavicular articulation may be inspected to discover a 
possible chronic inflammation, and the clavicle examined for recent 
or old fractures, tumors, etc. 

Note the condition of the mediastinum, especially as to emphy- 
sema and tumors, the ductus arteriosus, and the thymus and the peri- 
bronchial and other lymphatic glands. The latter are often pigmented, 
and for this reason are not infrequently mistaken by students for 
melanotic sarcoma. They are often tuberculous, and may be cancer- 
ous. Emphysema is sometimes produced artificially by the removal 
of the sternum at the time of the postmortem or by decomposition. 
When the lung is actually lacerated, the emphysema is more extensive 
and may extend even into the neck. 

Thymus Gland. — This weighs about 13.75 grammes at birth, and 
increases in size until the end of the second year, when it weighs about 
26.2 grammes. It then gradually diminishes and after puberty is nor- 
mally absent, though it has been observed in acromegaly, myxcedema, 
and many other pathological conditions. Hemorrhages are often 
found in the thymus of stillborn babes. Pus may occasionally be pres- 
ent. Mistakes have been caused by the altered appearance of the nor- 
mal secretion after it has undergone post-mortem change ; hence great 
care is necessary in making the diagnosis of suppuration. 

Hemorrhage into the mediastinum may be due to trauma, to 



EXAMINATION OF THE THORACIC CAVITY fry 

phosphorus poisoning, or to acute yellow atrophy- of the liver. An 
abscess may be found, or a chronic mediastinitis, marked by fibrous 
thickening and density of the connective tissue. The latter usually 
occurs in conjunction with a fibrous pericarditis (mediastino-pericar- 
ditis), and is of importance on account of its influence upon the heart 
action (Orth). 

The thyroid gland may at this time be examined in situ, or, if pre- 
ferred, it, together with the tongue, epiglottis, oesophagus, trachea, 
parathyroids, carotids, etc., may be removed en masse and studied sub- 
sequently. Note the position of the pericardium, whether or not it is 
distended with fluid, and to what extent it is covered by the lungs. 

Observe the appearance of the presenting portions of the lungs. 
The normal color of the lungs at birth is a pinkish-white; in adult 
life, a dark slate-color, mottled in patches; and as age advances this 
mottling becomes nearly or quite black, owing to the deposit of car- 
bonaceous material. Changes in color may be due to the amount of 
blood present or to some pathological process. 

When the thorax is opened, the normal lung retracts on account of 
its own elasticity. This contraction of the lung may not occur, because 
of the absence of elasticity, because of emphysema, because of pleural 
adhesions, because the alveoli are full of solids or fluids, the result 
of inflammation, or because stenosis of the larynx, trachea, etc., may 
prevent the egress of air. In cases of alcoholic intoxication and suffo- 
cation the lungs are very markedly expanded (Orth). 

If for any reason a pneumothorax is suspected, after having care- 
fully removed any opaque fluid present, fill the pleural cavity with 
water and inflate the lungs with air by means of an intubation tube 
connected with a pump by a piece of rubber tubing. The rising air 
bubbles will reveal the situation of the laceration in the lung. In ex- 
amining the pleural cavities inspect first the left and afterwards the 
right. Xote the amount of contained fluid, whether or not it is bloody 
or of an inflammatory nature, and whether or not adhesions are pres- 
ent. The remarks made upon the peritoneal fluid apply with equal 
force to that found here and in the pericardium. 

The pericardium should be grasped near its centre by the fingers 
or a tenaculum, and a longitudinal fold elevated before it is incised, in 
order to prevent injury to the heart or the escape of fluid. A small 
incision is then made at the highest point, under the strictest precau- 
tions if a bacteriological examination is to be made, and any fluid pres- 



58 POST-MORTEM EXAMINATIONS 

ent should be drawn off with a syringe or pipette into a graduated glass 
and its quantity noted. When there is much distention of the peri- 
cardial sac, the direction and length of its principal diameters — which, 
it should be remembered, are anatomically the reverse of those of the 
heart — should be noted before any fluid is allowed to escape. The 
opening in the pericardial sac may be enlarged sufficiently to admit 
two fingers, which are then spread apart and protect the heart while 
allowing the pathologist to cut between them. With a knife or a pair 
of scissors two downward cuts are made — one downward and to the 
right, the other downward and to the left — as far as the diaphragmatic 
attachment. The right flap is then drawn strongly forward away 
from the heart and another cut is made in an upward direction to the 
point where the pericardium is reflected around the vessels coining off 
from the heart (Fig. 60). 

About half an ounce of clear serous liquid is normally present in 
the pericardial sac. Normal pericardial fluid does not contain any 
fibrinous flocculi, though it may coagulate on standing. In hydroperi- 
cardium there is an increase in the amount of the pericardial fluid; 
this condition may follow passive congestion of the lungs or appear 
as a part of a general anasarca. The presence of blood in the pericar- 
dial sac, or hsemopericardium, may be a sequence of rupture of the 
heart or of an aneurism of the aorta, pulmonary artery, or coronary 
arteries ; or, when the blood is part of an exudate, may have resulted 
from an inflammatory process. Blood derived from the rupture of an 
aneurism, from trauma, etc., is always clotted, while that which is 
intimately mixed with a fluid exudate is derived from newly formed 
vessels of inflammatory tissue. Pneumopericardium may be due to 
rupture of the stomach or oesophagus or of the lungs, into the peri- 
cardial sac; or may be consequent upon the decomposition of an in- 
flammatory exudate. Foreign bodies, also cysticerci, echinococci, and 
trichinae, have been found in the pericardium. 

The signs of pericarditis are to be looked for. 

The normally transparent glistening membrane may have lost its 
lustre, or may be hyperaemic, thus indicating a dry fibrinous pericar- 
ditis. An abundant serofibrinous exudate is the result of a pericarditis 
serofibrinosa. In this condition, when there is much fibrinous exudate 
and little fluid, on account of the movement of the heart, the exudate 
is thrown into villoid projections and the characteristic cor villosum 
may be found. Newly formed granulation tissue may accompany a 



EXAMINATION OF THE HEART 



69 



fibrinous exudate, with the formation of a productive pericarditis. 
Suppurative pericarditis shows pus in the sac, the result of trauma, or 
secondary to suppurative mediastinitis, cancer of the ribs, gangrene of 
the lung, or a general infection. A chronic process may leave many 
extensive adhesions between the two layers of the pericardium, or a 
fibrous or adhesive pericarditis may cause a complete obliteration of 
the sac. 

Tuberculosis of the pericardium, most often associated with a 
fibrino-hemorrhagic exudate, may show tubercles along the course of 
the vessels, or old cheesy tuberculous foci may be found in chronic cases. 
Gummatous inflammation and metastatic carcinoma or sarcoma of the 
pericardium may occur. 

If an aneurism has been discovered, it is usually best not to separate 

the aorta from the heart, but to remove the aneurismal sac and the 

heart together. The aorta is not to be opened until the heart has been 

examined. In endocarditis vegetations are sometimes present in the 

arch of the aorta, and might easily be overlooked if not especially 

searched for. 

THE HEART. 

The heart is to be carefully observed before it is touched. Its nor- 
mal position may be altered by fluid in the pericardium or in the 
pleurae, by cardiac hypertrophy, in which case the apex may reach to 
the anterior axillary line, or by tumors of the mediastinum. The heart 
is about as large as the right fist. It measures from base to apex about 
85 to 90 millimetres in men and 80 to 85 millimetres in women between 
the ages of twenty and sixty years; its greatest transverse diameter 
varies from 92 to 105 millimetres in men and 85 to 92 millimetres in 
women; it is about 35 or 36 millimetres thick in men, and from 30 to 
35 millimetres in women. Any displacement is determined by the 
situation of the apex and the base, which are anatomically described 
especially in relation to the ribs, sternum, nipples, and median line of 
the body. Cardiac enlargement may be due to heart disease or sec- 
ondary to disorders of the lungs, kidneys, aorta, etc. The color of the 
surface of the heart depends very much upon the condition of the epi- 
cardium and the underlying fat. The auricles, especially when well 
filled, are dark blue, while the color of the ventricles differs with the 
condition of the muscle. The consistence of the various portions of 
the heart depends upon the degree of contraction of its muscular tissue, 
as well as upon the amount and composition of its contents (Orth). 



;o 



POST-MORTEM EXAMINATIONS 



The contraction (systole) and the relaxation (diastole) of the two 
auricles and the two ventricles are considered in relation to the amount 
of blood contained within them. The amount of blood, especially if it 
be fluid, does not afford a criterion of the quantity therein during life, 
owing to the free communication of the vessels and cavities of the 
heart. For example, after death by asphyxia the right side of the 
heart is distended with dark fluid blood, while after death from digi- 
talis the left ventricle is contracted. Overfilling of the left ventricle 
is found when death was caused by cardiac paralysis. For bacterio- 
logical examination or chemical analysis the blood is usually taken 
from the cavity which is most distended with it, unless, of course, for 
some reason blood from a special cavity or side is desired. 

The epicardium and the amount of subepicardial fat are to be care- 
fully observed, as well as milk spots. In cachexia the subpericardial 
fat may be transformed into a soft, transparent, gelatinous mass, which 
becomes whitish on the addition of acetic acid. This is the so-called 
mucoid change of the subepicardial fat. Small lipomata may be found 
near the apex; and small subpericardial ecchymoses— so-called spots 
of Tardieu — are of medicolegal importance, as they are frequent in 
cases of death due to suffocation, particularly in the new-born, but may 
occur in the infectious fevers, as in diphtheria. 

The situation of the coronary arteries should be noted, and the 
anterior one should be felt, to learn whether or not it is " pipe-stem" 
in character. The interior is to be examined when they are opened 
later on. The coronary veins are easily distinguished from the ar- 
teries by the relative thinness of their walls as well as by their course. 
Overfilling of the larger veins indicates an obstruction to the outflow 
of blood from the right auricle ( suffocation, etc. ) , unless it be confined 
to the posterior wall, in which case it is due to hypostasis. 

The interior of the heart is now T to be examined, and here again, to 
secure the best results, it is necessary to adhere to a definite plan of 
procedure. There are several so-called " methods" of opening the 
heart, but all have the same object and all accomplish it more or less 
completely, — viz., that of exposing the cavities and valves with the 
least possible interference with the septa and the parts subsequently to 
be examined, and in such a way as to permit of the organs being recon- 
structed, or returned to their original shape and relations. The method 
adopted and described by Virchow for use in the Berlin Charite is 
undoubtedly the best, although the others may, if thoroughly under- 
stood and properly executed, yield very satisfactory results. 




Fig. 58. — Shows the breastplate after its removal from the body 




Fig. 59. — The skin flap is placed over the projecting margins of the right clavicle and 
ribs in order to protect the operator's hands from injury. On the left side this has not been 
done. On the right side a transverse incision, Fig. 43, D, has been made, while on the left 
side the rectus muscle has been incised as in G of the same figure. 




Fig. 60.— Method of opening pericardium. The left hand supports the right flap of the pericardial 
sac, while the knife cuts the pericardium up to its attachment to the great vessels coming off from the 
heart. 






C S 

<U *-> 

q, in 

O _tn 

O C 

en .&> 



■ O 3 
/-' en 



EXAMINATION OF THE HEART y 1 

Ordinarily it is advisable that certain incisions be begun while the 
organ is still in situ and completed after it has been removed from the 
body. As each cavity is opened, careful note should be made of the 
quantity, color, and consistence of the contained blood and of the size 
and character of any clots that may be present. If the opening is 
occupied by a clot, this should be at once removed. 

Bacteriological examinations may be made while the heart is in 
situ, or in some cases may be facilitated by removing the heart before 
incising it. 

Primary Incisions. — After breaking up pericardiac adhesions, if 
present, the heart should be gently rotated on its long axis by slight 
pressure between the index-finger and thumb of the left hand, at the 
same time that slight traction is made downward and to the left of the 
body. This will bring the points of entrance of the superior and in- 
ferior venae cavae into view ; midway between which the first incision 
is begun and then carried downward in the direction of the right ven- 
tricular ridge until the right auriculoventricular septum is reached 
(Fig. 61, A B, and Fig. 64). Next make an incision in the right 
ventricle, just below the auriculoventricular septum, passing down the 
right ventricular ridge to the interventricular septum, which is a little 
to the right of the apex (Fig. 61, CD). On the left side make an 
incision in the auricle, beginning in or slightly below the lowermost 
pulmonary vein and continuing in the direction of the left ventricular 
ridge as far as the auriculoventricular septum (EF). Open the left 
ventricle along the entire length of the left ventricular ridge, and, as 
this ventricle normally forms the apex of the heart, the incision will 
be carried to and through that point before the ventricular septum is 
reached (Fig. 61, G H, and Fig. 65). This incision must not join 
that of the other ventricle, but should be separated by an interval of 
about one-half inch. From the fact that these incisions are made 
while the heart is still in situ, they may be called primary incisions. 

In cases of sudden death in which an embolus of the pulmonary 
artery is suspected, it is best to open that blood-vessel before re- 
moving the heart. This assures the finding of the embolus, which 
might otherwise be obscured in cutting the pulmonary artery for re- 
moval of the heart. By this method, also, the ductus arteriosus and' 
congenital heart lesions in infants may be investigated. 

Removal of the Heart from the Body. — To remove the heart, 
introduce the index-finder and thumb of the left hand into the left 



72 



POST-MORTEM EXAMINATIONS 



and right ventricles respectively, grasp the ventricular septum near 
the apex, and elevate the heart sufficiently to make slight traction 
on the great blood-vessels (Fig. 66). Then, if no aneurism be pres- 
ent, sever all the normal attachments as near their point of passage 
through the pericardium as possible, and in the following order, — viz., 
the inferior vena cava, the superior vena cava, the pulmonary artery, 
the aorta, and lastly the pulmonary veins. Avoid injury to the oesopha- 
gus during the removal of the heart from the body. Or, the heart 
is drawn outward preparatory to severing the vessels, as seen in 
Fig. 67. 




Fig. 67. — The pulmonary veins are placed on a stretch, and are ready to be incised. 



Measuring and Testing the Valves. — Immediately upon the re- 
moval of the heart from the body, the blood and clots should be care- 
fully removed from about the valves. The valvular openings are then 
to be measured. Their size is usually estimated by the number of 
fingers that the ostium will admit. Normally the mitral ostium will 
admit the index and middle finger, whereas through the tricuspid open- 
ing the index and middle finger of one hand and the index-finger of the 
other hand can be introduced. This method is, of course, convenient, 
but is very unscientific and inaccurate and should be superseded by the 




Fig. 64. — Method of opening the right auricle ; incision is made down to the auriculoventricular 
septum of the right side. This incision is usually made while the heart is in situ, but for the sake of 
clearness is here shown as being made outside of the bodv. 




Fig. 65. — Method of opening left ventricle. The heart is being opened outside of the body. The left 
hand steadies the heart while the knife cuts along the left ventricular ridge, starting just below the 
auriculoventricular septum and ending at the apex. 




Fig. 66. — Method of removing the heart from the body. The index-finger is placed in the left ven- 
tricle and the thumb in the right ventricle, and the ventricular septum is grasped. The heart is then 
raised-i'upward and towards the chin, placing on a stretch the blood-vessels which enter the heart. 
These are cut, starting with the lower pulmonary vein and going from left to right in a circular direction 
until the upper pulmonary veins are reached, or the initial incision may be made at the inferior vena cava 
and end with the pulmonary veins. 




Fig. 68. — The pulmonary artery is made tense with the left hand, while from the centre of the right 
ventricular incision the anterior portion of the right ventricle is cut in the direction of the thumb and 
middle finger which mark the junction of the two anterior pulmonary semilunar cusps. 




Fig. 69. — The left auricle and ventricle are fully opened, exposing the mitral valve, chordae tending 

papillary muscles, endocardium, etc. 




Fig. 70.— Completed incisions of the heart, the organ having been reconstructed after the examination 

of all its cavities and parts. 



EXAMINATION OF THE HEART 



73 



use of a constant unit of measure. Graduated cones, or balls of defi- 
nite sizes (Figs. 38 and 39), placed on rods, answer the purpose very 
well. They are gently inserted in the direction of the blood-current, 
and the exact size of the opening can then be given in millimetres or 
inches. Vegetations upon the valves may be injured by their careless 
use. An equally scientific method is to measure the attached margins 
and to determine the diameter by dividing by 3.14 (tt). 

The competency of the valves should now be tested. To do this, 
trim the great vessels down so that the valves may be seen. The heart 
is then evenly supported by each of the vessels in turn, — i.e., held in 
air and in such a way that the semilunar valves will be as nearly hori- 
zontal as possible, at the same time receiving no unnatural support 
from beneath. Water or mercury is then gently poured in by a second 
person until the vessel is filled, and note is made of the action of the 
valve. In case no one else is present, the heart is to be held under 
water and then quickly taken out, and the valve being tested observed. 
If there is any leakage from the aorta, make sure that it is not from 
a branch of one of the coronary arteries. The best result of the water- 
test is seen in the semilunar valves, the competency of the auriculo- 
ventricular valves not being accurately determined by this method, 
which has of late rather fallen into disuse. 

Should it be necessary or desirable to ascertain the competency of 
the auriculoventricular valves, the primary incisions above described 
are not made until the heart has been removed from the body, and the 
test is begun by cutting a transverse slice from the apex and exposing 
the ventricles. The heart is now everted and each ventricle is filled 
separately with liquid. This method of removing the organ before 
opening is also useful in examining the heart of a child or when it is 
desired to make a bacteriological examination of the valves. In the 
latter event no water should be used, lest some of the vegetations be 
washed out or other bacteria than those present be introduced, thus 
creating more or less serious confusion. 

Hamilton advises the use of air for testing the competency of the 
valves, and gives the- method as follows: 1 " An incision is first made 
into the left auricle, and any post-mortem clots are carefully removed 
from the left chambers through it. Another incision large enough to 
admit the nozzle of a half-inch tube is made into the ventricle near its 



'Hamilton, Text-book of Pathology, vol. i. p. 9. 



7 4 POST-MORTEM EXAMINATIONS 

apex and in the line of that required for laying it fully open. The 
tube is joined to a bellows, and air is driven intermittently into the 
ventricle by means of it, the aorta having been meanwhile closed. The 
valve will be seen to open and close, according as the air is aspirated 
or driven out of the bellows. A like procedure is adopted for the dem- 
onstration of the tricuspid. To test the aortic valve, the incision 
Defore described as necessary to lay open the left ventricle is continued 
up as close to the valve as possible without injuring it. The tube is 
tied into the aorta, and the action of the valve is watched from below. 
The same method is used to test the competency of the pulmonary 
artery valve. As a matter of fact the tricuspid, in the human heart, 
will always be found more or less incompetent." 

Secondary Incisions. — Place or hold the heart with its posterior 
surface downward. This can be told by the situation of the pulmonary 
artery, which is situated anteriorly. Insert a pair of probe-pointed 
scissors or the blade of the enterotome (now a cardiotome) in the in- 
cision in the right ventricle, and cut from the centre of that incision 
through the centre of the attachment of the two anterior leaflets of the 
pulmonary artery (Fig. 62, I J, and Fig. 68). The point of junction 
of the anterior leaflets can usually be seen from the outside, but, if not, 
it can very easily be determined by looking into the vessel or feeling it 
with the index-finger. This incision is to be continued until it opens 
up the entire portion of the pulmonary artery which has been removed 
from the body. Some pathologists advise making this incision towards 
the left of the pulmonary artery, so as to cut between the left anterior 
and posterior cusps. The right ventricle is now exposed so that the 
condition of the pulmonary valves, endocardium, myocardium, chordae 
tendinese, etc., of this side of the heart may be noted. Now dissect 
away the connective tissue binding together the pulmonary artery and 
the aorta. 

In opening the left ventricle, cut the anterior wall as near the ven- 
tricular septum as possible, starting from the apical extremity (H) 
and stopping at the point overlapped by the left auricular appendix 
(K). Then, using the cardiotome, the incision is completed (either 
from the aorta or from the ventricle) by cutting between two leaflets 
(L K). In the aorta there is but one anterior leaflet, consequently the 
incision should be to either one or the other side, but preferably as 
close as possible to the curves of the pulmonary artery. After ex- 
amining the valves, myocardium, aortic intima, etc., dissect out the 
coronary arteries with probe-pointed scissors. 



EXAMINATION OF THE HEART y- 

Lastly, unite the auricular and the ventricular incisions of each 
■side by cutting through the auriculoventricular septa (Fig. 63). In 
Fig. 69 is shown how well the auricle and ventricle of the left side 
may be examined after the completion of the incisions. 

The heart now freed from blood and clots is to be weighed. The 
valves will not be injured by this method and the entire heart can be 
folded together so as to show its original contour (Fig. 70). In 
extreme mitral stenosis it is often advisable not to complete the left 
auriculoventricular incision. 

The simplest method of opening the heart, and one which yields 
fair results, is to place two fingers on the anterior ventricular septum, 
which is recognized by the situation of the anterior coronary artery, 
and make two parallel incisions into each ventricle. Incisions may 
then be made through the pulmonary artery and the aorta. If it be 
desired to follow out the subclavian vessels, the entire clavicle of that 
side should be removed by careful dissection. 

The situation of the mitral and pulmonary valves can be easily re- 
membered by the mnemonic Martin Luther, The Reformer, — mitral on 
the /eft side, tricuspid on the right. There is but one posterior cusp to 
the pulmonary and one anterior cusp to the aorta, which fact affords 
an easy way to recall this oft-forgotten point. 



CHAPTER VIII 

LESIONS OF THE HEART, BLOOD, AXD BLOOD-VESSELS 

Characteristics. — The gross appearance of the heart, as well 
as the thickness, color, and consistence of the various parts of the 
cardiac muscle, can now be observed. The wall of the right ventricle is 
normally from 2 to 3 millimetres thick (in women slightly less than in 
men) and may pathologically be from 7 to 10 millimetres thick. The 
thickness of the wall of the left ventricle is from 7 to 10 millimetres, 
and may be increased to 25 millimetres or more by pathological 
changes. The estimation of the weight of the heart is one of the 
means of determining whether or not a true hypertrophy is present. 
The normal heart weighs about 250 grammes in women and about 
300 grammes in men; but when hypertrophied it may weigh over a 
kilogramme. The color of the heart muscle varies according to the 
amount of blood it contains, but is always lighter and more grayish, 
red than the skeletal muscles. The heart muscle may be of a brownish 
red or even brown, as in anaemia and brown atrophy of- the heart, where. 
with its tortuous vessels and mucoid covering, in some cases it varies 
from yellowish to a distinct yellow, which color is usually not uni- 
form, but scattered in patches throughout the muscle, or in bands 
making a sort of net-work (wren's breast or tiger markings). This 
yellow streaking is often most conspicuous on the papillary muscles 
of the left ventricle. In septic conditions the heart is of a dirty-red 
color. Light-gray spots or streaks indicate the formation of fibrous- 
tissue. The consistence of the heart muscle varies with the color: 
brown hearts are hard and dense, while those of a yellowish tinge 
are soft and flabby. After dilatation of an hypertrophied heart sets 
in, the muscle becomes softer by the process of fatty degeneration. 
The heart muscle is very soft in sepsis, also in cases of heart weakness- 
developing after an infectious disease, especially after typhoid fever 
and diphtheria. 

Anomalies. — Abnormalities in the development of the heart vary 

exceedingly. Dextrocardia may be the only abnormality of the chest,. 

or a part of a general situs inversus confined to the thoracic organs. 

An increase or decrease in the number of the semilunar leaflets may 

76 



LESIONS OF THE HEART, BLOOD, AND BLOOD-VESSELS 77 

be met with, and a circumscribed thickening of the muscle may occur, 
. and may cause a stenosis of the aorta if there situated. There may 
be an insufficient development of the whole heart, hypoplasia, found 
in cases of chlorosis; or a patulous foramen ovale. In the examina- 
tion of the auricles an aperture in the foramen ovale may be over- 
looked if the heart is so held as to put the auricular wall on the stretch. 
As the openings most frequently come off from the sides, this method 
of holding the heart will very often prevent their discovery. All sus- 
picious cracks or orifices should be searched for with a pointed probe 
£*while the heart is relaxed, care being taken not to tear or puncture 
the tissues or to mistake the mouths of veins for pathological open- 
ings. With a defect or an opening in the interventricular septum is 
often associated a stenosis of the conus pulmonalis, with a narrowing 
of the pulmonary valve. In these cases the ductus arteriosus may be 
patulous. Atresia of the mitral or tricuspid valves may be due to 
faulty development or to inflammation. Fenestration of the semilunar 
leaflets is of frequent occurrence and has no particular significance. 

Blood. — Many of the changes which the blood undergoes are 
macroscopical and can be studied at this point, especially if the in- 
nominate veins be opened. 1 There may be observed all degrees of 
coagulation, from an almost absolutely fluid condition of the blood 
to a hard and dense fibrinous clot, — the so-called heart polyp, — 
which contains almost no red blood-corpuscles. The firm, yellowish 
"" chicken-fat" clots may adhere to the walls of the heart, and indicate 
slow death, with gradual paralysis of the heart's action. When all 
the coagula are rich in fibrin, some acute inflammatory process has 
caused an increase in the leucocytes and blood-plaques, the generators 
of fibrin. Normally the clots in the beginning of the aorta and of 
the pulmonary artery contain a large percentage of fibrin. In the left 
auricle they at times assume polypoid or ball shapes. The ordinary 
post-mortem coagulum is the red clot, the so-called currant- jelly clot, 
which is not attached to the endocardium, though it may adhere to 
the interstices of the heart. Hyperinosis, or increased capability for 
fibrin formation in the blood, is met with at times, in certain anaemic 
affections and infectious diseases. Hypinosis, or decreased capability 
for fibrin formation, occurs in leukaemia, in hydraemia, and when the 



1 A small spectroscope and a Tallqvist haemoglobin scale are very useful for 
studying the blood at the postmortem. 



yS POST-MORTEM EXAMINATIONS 

blood is overladen with carbonic acid, as in cases of suffocation, or 
intoxication with gases, and in many of the infections. Blood satu- 
rated with carbon dioxide. is very dark in color; in cases of poisoning- 
by that gas the blood when exposed to the air quickly oxidizes. Methae- 
moglobin, found in cases of poisoning by chlorates, nitrites, toad- 
stools, etc., gives a brownish tinge to the blood. The blood in cholera, 
where anhydrsemia is present, is very thick, while in diseases of the 
heart, lungs, kidneys, and liver in which hydraemia is present the blood 
is thin and watery (Orth). In chlorosis and pernicious anaemia the 
blood is pale, particularly so in the latter, where it is even raspberry red,^ 
while in lipaemia, in which fat occurs free in the blood-plasma, and 
leukaemia a milky appearance of the blood may be noted. In putrefac- 
tion if the blood be left standing the clear serum separates and the 
sediment is yellowish green. Under the microscope shadows of red 
cells are seen. 

Pathological Conditions. — (a) Plethora Vera. — A condition in 
which all the elements of the blood are proportionately increased, (b) 
Plethora Serosa. — A marked increase in the watery constituents, (c) 
Olygcemia. — A diminished amount of blood; occurs only as a tempo- 
rary condition, (d) Hydrccmia, Anhydrccmia. — Abnormal increase or 
decrease in the watery portion of the blood. In anhydraemia the blood 
becomes thick and even tarry, as in cholera. In hydraemic plethora there 
is an absolute increase of serum. If relative it is an oligocythaemia. 
(e) Hemolysis. — Destruction of red corpuscles ; occurs after burns, cer- 
tain poisons, infectious fevers, etc. (/) Polycythemia rubra is an abso- 
lute increase in the reds, (g) Anccmia. — A diminution in one or more 
of the constituents of the blood, (h) Primary, Essential, or Idiopathic 
Anccmia. — An anaemia, the cause not definitely known, usually attrib- 
uted to the blood-making organs, and characterized by a dispropor- 
tionate reduction in the elements of the blood. (/) Secondary, Simple, 
or Symptomatic Anccmia. — An anaemia due to a definite cause, as an 
infectious fever, and characterized by a proportionate reduction in the 
elements of the blood. (/) Poikilocytosis. — Alteration in the shape of 
red corpuscles (crenated, reniform, and pyriform are most common). 
(k) Leucocytosis. — Increase in the number of white blood-cells without 
alteration of the relative numbers of each variety. (/) Leucopenia. — ■ 
A diminution in number of white blood-cells; seen most characteristi- 
cally in typhoid fever, (m) Lipccmia. — Fat in the blood. Diabetes. 
(n) Urccmia. — The presence in the blood of an excess of chemical com- 



LESIONS OF THE HEART, BLOOD, AND BLOOD-VESSELS yg 

pounds, as urea, which should be eliminated by the kidneys or other 
excretory organs. There may be an increase in blood-plaques, as is 
supposed to occur in purpura. 

Abnormal Constituents of the Blood. — (a) Tumor cells, as in renal 
sarcoma, the cells growing into the veins, (b) Pigment particles, as in 
malaria, (c) Haematoidin crystals, (d) Bilirubin crystals. These 
may be so considerable as to produce to the naked eye an orange-red 
color, or when the buffy coat of a clot or when a clot well washed in 
water is seen microscopically, usually in the shape of needles. Occur 
in icterus neonatorum, in pernicious anaemia, acute yellow atrophy, 
pyaemia, but not in ordinary icterus, (e) Gas bubbles, — due to putre- 
faction, to air-producing bacteria which develop very rapidly after 
death. In fresh blood air bubbles, particularly when seen in the right 
heart and surrounded by a clot, are due to the entrance of air into the 
veins during life. (/) Charcot-Leyden crystals, — leukaemia. (g) 
Lower organisms, — I. Spirochaetae of relapsing fever (not always 
found after death). 2. Anthrax. 3. Cocci, — micro-, strepto-, diplo-, 
etc. 4. Plasmodia. 5. Filaria sanguinis hominis. 6. Distoma haema- 
tobium. 7. Trypanosoma. 

Many names have been given to such conditions, as septicaemia, 
where there are pyogenic micro-organisms in the blood and tissues, 
without areas of suppuration; pyaemia, where metastatic or pyaemic 
abscesses are found in the tissues and organs of the body, and saprae- 
mia, where the symptom-complex is produced by the presence in the 
blood and tissues of the vital chemical products known as toxins. These 
toxins may be formed by the action of pyogenic or saprophytic micro- 
organisms. 

Blood-Diseases. — Anccmia, Progressive Pernicious. — An idio- 
pathic, chronic anaemia characterized by definite blood-changes, by a 
lemon-yellow coloration of the skin, and by progressively developing 
weakness without corresponding- emaciation. Etiology : (a) Most 
common in the male sex. (b) Overwork, (c) Bad hygiene, especially 
poor teeth and unclean mouth, (d) Adult life, though the disease may 
occur in children, (e) Intestinal parasites. (/) Pregnancy and par- 
turition, (g) Atrophy of the gastric tubules. I. Blood. — (1) Marked 
reduction in number of red corpuscles (to one million or less per cubic 
millimetre). (2) Alteration in their shape, — poikilocytosis. (3) 
Alteration in size, — microcytes, macrocytes, megalocytes. (4) Nu- 
cleated reds, — normoblasts, megaloblasts. (5) Increase of neutro- 



g Q POST-MORTEM EXAMINATIONS 

philic whites. (6) Haemoglobin markedly decreased, but color-index 
usually high. II. Miscellaneous Lesions found Post Mortem. — (i) 
Muscles resemble horse-flesh. Heart usually large, flabby, empty, 
and tawny-brown. (2) Spinal cord may show posterior sclerosis 
with hemorrhagic foci. (3) Skin and serous membranes commonly 
reveal hemorrhages ; these may, however, be present only in the retina. 
(4) All organs exhibit fatty changes. (5) Iron is deposited in excess 
in the lobules of the liver, especially in the outer and middle zones. (6) 
The bone-marrow — best seen in the humerus or femur, though also 
found in the clavicle — is red (lymphoid) in character. 

Chlorosis. — Chlorosis is a primary anaemia which occurs usually in 
girls, and is characterized by marked diminution of haemoglobin and 
sometimes by hypoplasia of the circulatory and generative organs, (a) 
Female sex. (b) Age from fifteen to twenty, (c) Bad hygiene and 
overwork, (d) Shock or fright, (e) Absorption of intestinal poison. 
Cases of simple chlorosis rarely come to autopsy. The blood shows 
marked diminution of haemoglobin. In severe cases there may be great 
alterations in the number, shape, and size of the red corpuscles. The 
white rarely show much variation. The flesh is usually well preserved. 
The skin is pale and of a greenish hue, and there may be other evidences 
of anaemia. The internal organs will be found pale and flabby. The 
heart and larger blood-vessels and the generative organs show hypo- 
plasia. 

Leucocythcumia (or Leukaemia). — A form of primary anaemia 
characterized by great increase of the white corpuscles and by marked 
structural changes in the lymphatic glands. Cause: Not definitely 
known ; usually ascribed to changes in the blood-making organs. Clas- 
sification. — (a) Splenic, (b) Medullary, (c) Lymphatic, (d) Com- 
binations of the three forms. As a rule, the patient is apparently well 
preserved, but in some cases emaciation may be extreme. The skin 
has a peculiar lemon-yellow color. The mucous membranes are 
blanched. The amount of adipose tissue is frequently increased and 
of a peculiar punctate appearance, owing to the presence of petechial 
hemorrhages. The blood is pale in color, — often milk-white. It rarely 
clots with any rapidity. The organs in general are pale; the liver, 
spleen, and lymphatic glands are usually markedly enlarged. The heart 
is pale, flabby, and frequently fatty in appearance, (a) In splenic 
anaemia, which is a comparatively rare form of the disease, the spleen 
is markedly enlarged, somewhat firm in consistency, and of a reddish- 



LESIONS OF THE HEART. BLOOD. AND BLOOD-VESSELS 8l 

brown color. The Malpighian bodies are frequently obliterated, their 
place often being taken by grayish-white, circumscribed tumors 
throughout the organ. The hyperemia in some cases is excessive, and 
rupture of the spleen is said to have occurred from this cause. Dropsy 
from pressure on the abdominal viscera may result. As in other forms 
of leukaemia, the bone-marrow may show decided changes, especially 
in the long bones. Instead of fatty tissue there may be splenization, 
or it may resemble the consistent matter which forms the core of an 
abscess. Microscopical examination of the blood shows that the in- 
creased white corpuscles are largely myelocytes, (b) Medullary leukae- 
mia very seldom occurs as an inflammatory process. Where the marrow 
changes are excessive, the flat bones — as, e.g., the sternum — undergo 
alterations similar to those occurring in the long bones, (c) In lym- 
phatic leukaemia the lymphatic glands throughout the body, especially 
those of the neck, the axillary and inguinal regions, and the glands of 
the mesentery and the intestines, show marked involvement. The liver, 
as well as the spleen, is enlarged and may exhibit marked structural 
changes. The lymphatic glands in general are swollen, pale in color, 
firm to the touch, and seldom suppurate or show any tendency to run 
together. The spleen, liver, and other lymphatic glands often show 
marked thickening of their capsules. On section the glands are some- 
what resistant, and often exhibit nodule-like bodies, which are firm in 
consistence and largely composed of proliferating leucocytes and con- 
nective tissue. Microscopical examination of the blood shows that the 
marked increase of the leucocytes is in the lymphocytes, (d) The 
blood in leukaemia in general shows somewhat marked diminution of the 
amount of haemoglobin ; it is light raspberry-red in color and may in 
the severest cases be yellow ; small balls of corpuscles, especially in 
the pulmonary artery, are sometimes seen ; the red corpuscles are 
reduced in number, sometimes markedly so. The white corpuscles are 
enormously and permanently increased, so that one white to twenty 
red, or even one to one, is not uncommonly found. The characteristic 
feature of leukaemic blood is the alteration of the relative proportions 
of the various white corpuscles the one to the other. 

Haemophilia. — An- hereditary constitutional disease characterized 
by a marked tendency to excessive hemorrhage from very slight causes. 
It is transmitted through the females of a family to the males. Little 
regarding the morbid anatomy is definitely known. The vessel-walls 
are unusually thin, brittle, and do not readily retract. In some cases 

6 



82 POST-MORTEM EXAMINATIONS 

the blood itself presents marked alterations. Hemorrhages have been 
found about the capsules of joints, with inflammation of the synovial 
membrane. 

Purpura. — A disease characterized by the appearance on the skin 
of numerous blotches of extravasated blood and by great debility. Very 
little is known of its origin. It is apparently more common in males 
than in females and more frequent in the young than in the old. Clas- 
sification. — The forms are (a) Purpura simplex, (b) purpura hemor- 
rhagica, (c) purpura rheumatica, (d) iodic purpura, (e) Henoch's 
purpura. Among the points revealed by autopsy are : ( i ) The exist- 
ence and extent of hemorrhagic effusions with evidences of anaemia. 
(2) Occasionally the skin presents erosions or ulcerations. (3) The 
hollow viscera and serous cavities may contain considerable quantities 
of blood-stained serum. (4) The serous membranes and solid organs, 
as well as the skin, may reveal hemorrhages varying in size from a pin's 
head to the palm of the hand. (5) Congestion and oedema of the lungs 
are frequently present. (6) Slight degrees of acute diffuse nephritis 
may occur. (7) Ulcerations of the intestines with enlargement of the 
solitary and agminated glands are sometimes present. In one of my 
cases the husband was accused of beating his wife and thus causing her 
death. 

Scurvy. — Caused by: (a) Deficiency of fresh vegetables, (b) 
Bad hygienic surroundings. (1) After death decomposition sets in 
rapidly. The hemorrhagic patches observed in the skin during life are 
soon obscured by post-mortem lividity. (2) The subcutaneous tissues, 
especially those of the lower extremities, contain a blood-stained fluid 
with here and there discolored patches, some black and others of a pale 
color. (3) About the back of the thigh and knee the muscles and 
tendons may be embedded in a thick, firm clot, and themselves contain 
numerous hemorrhagic foci. (4) The blood is dark and fluid. Hemor- 
rhages may be present in any of the serous membranes or internal 
organs. (5) The gums are swollen, sometimes ulcerated, and the teeth 
may have fallen out. (6) Hemorrhages in the mucous membranes are 
extremely common. Rarely there may be ulcers in the intestines. (7) 
The spleen is enlarged and soft, while fatty changes are constant in the 
liver, kidneys, and heart. (8) There is very little wasting of the subcu- 
taneous fat of the muscles. This disease is by no means so frequent 
as formerly, owing to better hygienic conditions and to the proper 
feeding of those in ships, prisons, work-houses, etc. 



LESIONS OF THE HEART, BLOOD. AND BLOOD-VESSELS 83 

Scurvy, Infantile. — Usually associated with improper food, such as 
malted or condensed milk. Cases, however, have been reported in 
breast-fed children. ( 1 ) The most important lesions are increased vas- 
cularity and extravasation of blood affecting the periosteum and bones, 
especially those of the lower limbs. Extensive hemorrhages are fre- 
quently found between the periosteum and the bone. They may also 
occur in the cavity of long bones, forming masses of blood-clots. (2) 
These deep-seated extravasations may give rise to muscular swellings 
and in some cases to extravasations in the joints. (3) Smaller extrava- 
sations have been observed in the pleura, lungs, spleen, intestines, and 
kidneys. (4) Fractures are not uncommon. In fact, in the majority 
of cases there are bone changes analogous to those of rickets. (5) The 
gums are spongy, sodden, distended with serum, and sometimes covered 
with blood. (6) One of the most characteristic lesions is extravasation 
of blood into the orbital cavity, causing displacement of the eyeball 
downward and forward. The report of the American Pediatric Society 
on this condition is of a most interesting character. 

Diabetes Insipidus. — A constitutional condition characterized by 
the passage of large amounts of pale urine, of low specific gravity, con- 
taining neither albumen nor sugar. It occurs more often in the male 
sex and during early life. Heredity may be a causal factor. The uri- 
nary system may merely show the signs of the passage of an abnormal 
amount of liquid. — enlarged and congested kidneys, dilated pelves, 
dilated ureters, and an hypertrophied bladder. 

Diabetes Mellitus. — A constitutional disease characterized by the 
passage of large amounts of pale urine, of high specific gravity, con- 
taining sugar. It occurs most frequently in adult males, Hebrews 
being specially predisposed. Mental strain or Avorry may be a cause. 
There are no constant lesions of the nervous system, but tumors of the 
medulla, injury of the floor of the fourth ventricle, or sclerosis in 
various areas have been found. The sympathetic ganglia may be en- 
larged and sclerosed and a secondary multiple neuritis is not rare. The 
cceliac ganglion is atrophic in this disease (Orth). Neuroretinitis is 
very common, and there may be hemorrhages in the retina and opacities 
in the vitreous. The most usual change is thickening and congestion of 
the membrane. Croupous pneumonia, bronchopneumonia, and tubercu- 
losis are common complications ; any of them may terminate in gan- 
grene. Fat embolism of the pulmonary vessels has been described. The 
lung may soften (malacia) and, becoming mixed with stomach secre- 



84 POST-MORTEM EXAMINATIONS 

tions post mortem, forms the so-called pneumomalacia acida. It has 
a sour but not a gangrenous odor. The pancreas is often diseased, espe- 
cially the islands of Langerhans. There may be simple atrophy, pig- 
mentary cirrhosis, cancer, calculi, cystic disease, or fat necrosis. The 
spleen is usually small, pale, and soft, but may be enlarged and con- 
gested. Diffuse nephritis with fatty degeneration occurs frequently, 
also glycogen degeneration, most marked in pyramids. Boils, carbun- 
cles, onychia, eczema, and gangrene of the extremities are common. 
The blood generally appears normal, but may be loaded with finely 
divided fat which floats on the surface in a cream-like layer. The liver 
is usually enlarged, often congested, abnormally firm to the touch, and 
gives the glycogen reaction ; fatty degeneration is common. ' The myo- 
cardium is pale and soft; rarely it may be hypertrophied. Advanced 
fatty degeneration of the muscular fibres is the characteristic change in 
long-standing cases of diabetes. The urine is of high specific gravity, 
of a pale, somewhat cloudy appearance, always containing sugar and 
sometimes acetone and diacetic acid. Do not mistake for alkaptonuria. 
Gout. — A constitutional disease characterized by deposits of uric 
acid or its salts in the joints of the extremities. Predisposing causes 
are: (a) Male sex. (b) English race, (c) Heredity, (d) High 
living. Anatomical changes are found most frequently in the great toe. 
though the disease shows a marked tendency to involve the smaller 
joints, both of the feet and the hands. In acute stages there are notable 
hyperemia and round-celled infiltration and diffusion into the joint. 
Macroscopically the joint is swollen, tense to the touch, of a purplish 
color, and glazed. In the chronic form the ligaments and fibrocarti- 
lages of the joint become infiltrated with chalky deposits (tophi). 
These consist of sodium urate in the form of crystalline needles or 
rhombs. The addition of hydrochloric acid causes their immediate dis- 
appearance, but later whetstone crystals of uric acid make their appear- 
ance. Necrosis in the cartilage always precedes the formation of tophi 
(Ebstein). These deposits may be slight or may lead to enormous 
distortion of the joint. In some cases the skin may ulcerate and the 
tophi be extruded. The deposits may be found in the cartilages of the 
ear, the nose, the eyelids, and occasionally the larynx. The kidneys 
usually show chronic interstitial inflammation with deposits of urates 
in the form of small flakes or stripes, chiefly in the pyramids. Arterio- 
sclerosis, with hypertrophy of the left ventricle, is very common. Cuta- 
neous affections, such as eczema, are not infrequent. 



LESIONS OF THE HEART, BLOOD, AND BLOOD-VESSELS 85 

Hemorrhages. — Disturbances of the circulation of the endocar- 
dium are rare, as this membrane possesses no blood-vessels of its own. 
A diffuse redness in this situation may, however, be the result of 
imbibition, and in the case of long-diseased valves, in which there are 
newly formed blood-vessels, reddish streaks and spots may be ob- 
served, which are due to small hemorrhages. In the myocardium 
larger hemorrhages may be met with, as a result of the rupture of 
small aneurisms of branches of the coronary arteries or as a hemor- 
rhagic infarct. Anaemic infarct is also found as a result of a partially 
obstructing embolus or the formation of a thrombus. The condition 
of softening of the heart, or myomalacia cordis, is 'most frequently 
situated in the anterior wall of the left ventricle, near the apex. The 
degenerated tissue may form a scar, but more frequently leads to an 
aneurismal dilatation, which may subsequently rupture. Aneurisms 
of the sinus of Valsalva may form and rupture in unexpected places ; 
I have seen, for example, an aneurism of an aortic sinus ruptured in 
the right ventricle. 

Varieties of Hemorrhage. — The following terms are applied to 
hemorrhages from various parts of the body : Epistaxis, hemorrhage 
from the nose; haemoptysis, pulmonary hemorrhage; haematemesis, or 
gastrorrhagia, hemorrhage from the stomach ; metrorrhagia, uterine 
hemorrhage not occurring during the regular menses; menorrhagia, 
excessive menstrual flow ; post-partum, hemorrhage from uterus after 
delivery; complementary, hemorrhage occurring in some place other 
than that in which the original bleeding occurred ; consecutive or sec- 
ondary hemorrhages; extrameningeal, a hemorrhage external to the 
cerebrospinal meninges ; hemorrhage per diapedesis ; hemorrhage per 
rhexis. 

Hemorrhages, Causes of. — (a) Traumatism, (b) Acute inflam- 
mation, (c) Passive congestion, (d) Corrosive poisons, (e) Malig- 
nant growths. (/) Diseases of the vessels, (g) Rupture of an 
aneurism, (h) Cachectic disease. (/) Dyscrasias. (y) Nervous dis- 
turbances, (k) Vicarious menstruation. 

Hypertrophy and Dilatation. — These conditions are usually 
associated with each other. In concentric hypertrophy the walls are 
thickened and the cavities are smaller than normal. As this condition 
is often due to post-mortem contraction or to marked systole, the heart 
should be soaked in tepid water before the measurements are taken. 
One may also distinguish simple hypertrophy, where overgrowth of 



86 POST-MORTEM EXAMINATIONS 

the walls is found associated with normal cavities; eccentric hyper- 
trophy, or hypertrophy with dilatation ; and pure dilatation without 
hypertrophy. The highest degrees of hypertrophy occur in cases of 
double aortic disease, where, too, moderator bands are sometimes 
found. 

Infiltrations and Degenerations. — In fatty infiltration, or 
obesitas cordis, there is an increase of fat in those places where it is 
normally deposited ; it starts from the outside and goes inward along 
the trabecular of connective tissue; while in fatty degeneration the 
change originates from within. In fatty infiltration the heart may be 
embedded within such an enormous deposit of fat as to leave no 
muscle exposed to view. Hyaline and amyloid degeneration may also 
occur, as well as calcareous infiltration, fragmentation, and segmenta- 
tion. 

Myocarditis. — Parenchymatous myocarditis may be diffuse or 
limited. When the inflammatory process involves all of the muscu- 
lature of the heart, as is frequent in the infectious diseases, it is char- 
acterized at first by the flabbiness and the turbid grayish-red color 
of the heart muscle. In the later stages there is much fatty degenera- 
tion. Segmentary parenchymatous myocarditis is marked by a cloudy 
appearance of the heart muscle, which is flabby and friable. (Orth.) 
Acute circumscribed interstitial myocarditis, or abscess of the heart, 
is usually a part of a general pyaemic disease, with infection through 
the coronary circulation. These metastatic abscesses occur in cases of 
puerperal sepsis, in osteomyelitis, and other intensely septic diseases, 
but particularly in cases of malignant endocarditis. There may be 
only a few abscesses or the heart substance may be studded with in- 
numerable suppurating points. In size the abscesses vary from the 
merest dots to cavities of the size of a cherry. Acute diffuse interstitial 
myocarditis occurs in various forms of infectious fevers. The affected 
heart muscle is soft and often distinctly friable ; there may be spots 
of hemorrhagic infiltration, but, as a rule, the color is rather lighter 
than that of the normal organ. The cavities of the heart are frequently 
dilated, particularly the left ventricle. Chronic interstitial myocar- 
ditis or fibrous myocarditis may also be diffuse or localized, though 
the circumscribed form is the most common. This fibroid overgrowth 
is very commonly met with at the tips of the papillary muscles, on the 
trabecular, or in the substance of the heart muscle, and often at the 
apex of the left ventricle, where it may lead to such a degree of atrophy 



LESIONS OF THE HEART. BLOOD, AND BLOOD-VESSELS 87 

that a chronic localized aneurism of the heart may be formed by the 
constant pressure of the blood upon this thinned area. The process 
is usually secondary, and is dependent upon primary disease of the 
coronary arteries, or disturbances of the circulation in the coronary 
arteries, consequent perhaps upon old age, alcohol, gout, syphilis, and 
■ the like. The characteristic change is the formation of dense, grayish 
sclerotic areas, which appear either as more or less irregular spots or 
as 'streaks or lines running in the direction of the fibres of the heart. 
The entire substance of the heart may be involved and thickening 
of the walls may result. (Stengel.) 

Endocarditis. — In the foetus endocarditis is usually situated in 
the right side of the heart; during extra-uterine life the lesion is most 
common in the left side. In the great majority ofcadult patients acute 
endocarditis affects the endocardium of the valves. — the mitral, the 
aortic, and the pulmonary valve in order of frequency ; but it is some- 
times found in the endocardium of the cavities of the heart, — in the 
left ventricle, the left auricle, and the right ventricle. Various names 
have been applied to these conditions, as simple, or verrucose, benign, 
ulcerative, septic, mycotic, rheumatic, syphilitic, diphtheritic, or malig- 
nant endocarditis. Such cases differ much in their appearance, even 
when produced by the same organisms. Endocarditis starts on the 
endocardium as a minute, roughened area, which is red in color and 
slightly elevated. This can easily be scraped off, but. if the spot where 
it was found is carefully examined, a small ulcer will be seen. More 
and more fibrin is deposited, and the corpuscular elements are caught 
in its meshes ; the organisms multiply, and the clot undergoes a lique- 
faction necrosis, the process not stopping" in the newly formed tissue 
but often penetrating the valves or even the walls of the heart. Endo- 
carditis is frequently a secondary affection, dependent upon inflam- 
matory disorders in other organs, such as suppurating wounds, puru- 
lent peritonitis, and pneumonia. Sometimes, however, the endocar- 
ditis forms the first local manifestation of an infection, the exciting- 
agent of which has left no recognizable traces at the seat of its entrance 
into the body. Embolic occlusion of certain vessels and metastatic 
inflammations in other organs, especially the kidneys, spleen, brain, 
and skin, are not infrequently associated with endocarditis (Ziegler). 
Such hemorrhagic areas are to be sought for in the palpebral con- 
junctiva; their discovery therein during the external examination of 
the body has more than once led me to suspect ulcerative endocarditis, 



88 POST-MORTEM EXAMINATIONS 

even where there was no clinical history of its existence. This obser- 
vation is of special value when a bacteriological examination of the 
heart is desired. These ulcerative areas on healing are replaced by 
scar tissue, which, by contraction and by various degenerative changes, 
such as necrosis, fatty degeneration, and calcification, gives rise to the 
most fantastic shapes and appearances of the parts affected. 

Valvular Diseases. — An extreme degree of mitral stenosis is seen 
in the so-called buttonhole mitral, which causes hypertrophy of the 
left auricle, followed by dilatation. Brown induration of the lungs, 
cyanotic induration of other viscera, and dropsical effusions may fol- 
low mitral incompetence. In aortic stenosis the valves are usually 
thickened, rigid, and cartilaginous; later they become calcified and 
the division betweenjjthe different cusps is lost. First there is ventricu- 
lar hypertrophy, later right-sided enlargement, and finally dilatation 
with pulmonary congestion. In aortic incompetency arteriosclerotic 
changes are marked, being seen not only in the valves but also in the 
aorta. 

Syphilis, Tuberculosis, Actinomycosis, Tumors, etc. — Syph- 
ilitic gummata appear in the heart as rather large yellow foci sur- 
rounded by fibrous tissue; they may also be found in the arch of the 
aorta. Miliary tubercles, when present, are usually subendocardial 
or situated in the large vessels coming off the heart. At a postmortem 
in Ziegler's mortuary I once saw where a caseating peribronchial gland 
had eaten its way through the pulmonary artery and given rise to a 
most marked local and general miliary tuberculosis. Actinomycosis 
has been observed. Tumors are rare ; myxomata, lipomata, fibromata, 
sarcomata, and rhabdomyomata may be met with as primary tumors 
of the heart, while, as secondary, carcinomata, sarcomata, and espe- 
cially multiple melanotic sarcomata may be observed. Foreign bodies, 
as needles, pieces of bone, etc., have been found in the cardiac wall 
and even in the cavities of the heart. Cysticerci, echinococci, and very 
rarely pentastomata are sometimes discovered in the various parts of 
the heart. 

Arteries, Morbid Changes in. — Arteriosclerosis. — A hardening 
of the arteries, characterized by a diminution in elasticity of the vessels 
and marked alterations in blood-pressure. It may be local or general. 
Due to: (a) Old age. (b) Chronic disease, — e.g., gout, rheumatism, 
syphilis, etc. (c) Overwork, especially early in life, (d) Chronic poi- 
soning, — by lead, arsenic, alcohol, etc. (<?) Infectious diseases, etc. The 



LESIONS OF THE HEART, BLOOD, AND BLOOD-VESSELS 89 

arch of the aorta is the most common seat. In the first stage there is a 
loss of elasticity, due to hyaline or other changes in the subendothelial 
coat, and the intima is thickened. The second stage is characterized by 
a thickening of the media, atrophy of muscular and elastic tissue, with 
proliferative changes in all the coats; this increase of new tissue gives 
rise to pressure on the vasa vasorum, with interference of nutrition, 
which leads to the third stage. This consists of more or less marked 
macroscopic changes. The vessels are hardened, firm to the touch, do 
not retract or close when cut, and their lumina may be smaller or larger 
than normal. On the intima may be seen milk-white or yellowish 
patches, calcareous plates, abscesses (which consist of fat, cholesterin, 
and detritus), or ulceration. There may be a marked tendency to dila- 
tation with the formation of an aneurism or to contraction with oblit- 
eration. Special Forms. — (a) Senile. Affects larger arteries most; 
they are dilated, tortuous, thin but stiff; often show atheromatous 
changes in intima. Cyanotic induration of heart, liver, and kidneys is 
common, (b) Nodular. Knob-like yellowish- white projections are 
seen in the aorta and its branches, particularly about the orifices ; sud- 
den dilatation or aneurism may result, (c) Diffuse. The lesion is 
wide-spread and more uniform; the intima, as a rule, does not sIioav 
marked naked-eye changes. Cardiac hypertrophy is constant; the 
kidneys are sclerosed, their capsule is adherent, cortex irregular and 
often cystic, (d) Endarteritis obliterans. There is particularly a thick- 
ening of the intima. It is not uncommon at the base of the brain. 

Amyloid Degeneration. — Usually microscopic, and best brought out 
by staining. Atrophy. — A general diminution in the size of arteries, 
best seen in stumps after operations. Calcareous Infiltration. — In the 
media of the arteries of the old, particularly involving those of the 
extremities, calcification of the media occurs. It interferes with the 
blood stream, predisposes to thrombosis, and may be the cause of senile 
gangrene. Seen as a diffuse or circumscribed process, usually in con- 
nection with atheroma. Fatty Degeneration^ — In fatty degeneration 
the affected areas of the intima have a white or a citron-yellow appear- 
ance. These areas occur in the form of points, stripes, regular or irreg- 
ular or net-shaped figures. A frequent location is the posterior wall of 
the aorta around the origin of the intercostals. For more careful 
macroscopic study the surface of the fatty area should be removed 
with a fine forceps and in the centre a shallow incision should be made. 
Here small and large fat droplets can be seen. When placed in Flem- 



g POST-MORTEM EXAMINATIONS 

ming's solution these droplets become black. The fatty degeneration 
may involve the media and even be the cause of rupture. Hyaline De- 
generation. — Almost always microscopic; affects mostly the elastic 
coat and is often the beginning of an arteriosclerosis. It most fre- 
quently involves the small arteries. Hypertrophy. — There is hyper- 
trophy of the muscular layer in some diseases of the kidney, and 
hypertrophy of this layer in arteries of medium size in aortic insuf- 
ficiency. A general enlargement, best seen in the collateral circulation 
after ligation of a large vessel. Hypoplasia. — Hypoplasia of the aorta 
is congenital and is the result of stenosis, most commonly situated near 
the insertion of the ductus arteriosus Botalli. It usually soon causes 
death; if not, the aorta is contracted, thinner, but very much more 
elastic. Virchow attributes chlorosis to it. Inflammations. — I. Acute 
endarteritis (proliferative or obstructive endarteritis, thrombo-arteri- 
tis). This starts with an injury to the endothelium, proliferation 
occurs, and an obstruction is formed in the vessel-wall, on which a 
thrombus forms, partially or completely obstructing the vessel. This 
may terminate in absorption, suppuration, ulceration, or fibroid change. 
II. Chronic endarteritis. This usually follows the acute form, but is 
sometimes primary. It may be local (organization of a thrombus) or 
general (arthritis deformans). Syphilis. — Numerous small foci of cell 
infiltration, necrosis, and particularly induration, with small thicken- 
ings of the inner surface, are said by Heller, quoted by Orth, to be 
characteristic differences between syphilis and chronic aortitis. Gum- 
mata are rare. May be local or general sclerosis ; is usually a diffuse 
process, affecting all the coats, especially the intima. Tuberculosis. — 
Tuberculous lesions are less common in the arteries than in the veins. 
The small arteries are most frequently affected, and the pia, the brain, 
the kidneys, and particularly the lungs are the usual locations of such 
a lesion. Commonly a local process ; it may arise as an internal tubercle 
(gray nodule) of hsematogenous origin starting in the intima or as 
an extension from a neighboring tubercular process. Cheesy peribron- 
chial glands may ulcerate through the pulmonary artery and thus give 
rise to miliary tuberculosis. Thrombosis and embolism, especially in 
the brain, are of extreme importance. In embolism air, fat, portions 
of tumors, micro-organisms, etc., are brought to a smaller vessel from 
a larger one, though the converse may occur, and there set up charac- 
teristic changes, as infarcts, softening, abscesses, etc. 

Aneurism. — An aneurism is a circumscribed, tumor-like dilatation 



LESIONS OF THE HEART, BLOOD. AND BLOOD-VESSELS 91 

of an artery, containing blood in direct connection with the blood- 
current. A true aneurism has a sac composed of one or more of the 
arterial coats. A false aneurism is one in which some of the walls are 
formed by the tissues surrounding an opening in the artery; these 
sometimes attain an enormous size. Aneurisms may be caused by : 
(a) Arteriosclerosis, (b) Strain or traumatism, (c) Embolic and 
mycotic processes. The elastic coat is now believed to be the starting- 
point of aneurismal changes. Varieties: Cylindrical, when there is 
widening in all directions ; saccular, when one side is affected ; cirsoid, 
Avhen a large extent, or even the whole ramification, of an artery 
becomes dilated and tortuous ; this form most often occurs in the 
frontal, occipital, or iliac arteries ; arteriovenous, when there is com- 
munication between an arterial aneurism and a vein ; varicose, when an 
artery and a vein communicate through a false aneurism lying between 
them ; dissecting, when blood circulates between the coats of an artery. 
Extensive degeneration must precede this form. I have seen such an 
aneurism, which began at the transverse arch of the aorta, open again 
into the blood-stream just above the aortic bifurcation. Mycotic aneu- 
risms are multiple and are micro-organismal in origin. This variety 
is often seen in connection with malignant endocarditis. The mesen- 
teric arteries of the horse sometimes become dilated with considerable 
numbers of the Strongyhis annatus. Miliary aneurisms are usually 
multiple and consist of small dilatations ; they are found especially in 
the brain and lungs, and often antedate a hemorrhage in these regions. 
They are best seen in the brain by excising the middle cerebral artery 
and floating it out in a white dish partially filled with water. These 
aneurisms may be due to emboli. They are mostly sac-shaped and may 
attain the size of a cherry-stone. 

The walls of the blood-vessels may be present or altogether absent ; 
they may be thickened and opaque or almost transparent. If the aneu- 
rism be large, the cavity has a roug"hened wall, often lined with endo- 
thelium, and frequently contains clots which are white, red, organized, 
or softening. They frequently show lamination. I have seen a fibri- 
nous clot of an aneurism of the carotid mistaken for a sarcoma of the 
neck, a gluteal aneurism opened for an abscess, and a femoral aneurism 
mistaken for a hernia. Rupture of an aneurism, usually from the aorta 
into the pericardium, is a most frequent cause of death in cases brought 
to the notice of the coroner. The rupture often occurs during the act of 
defecation. Three cases of aneurism of the sinus of Valsalva have 



g 2 POST-MORTEM EXAMINATIONS 

come under my notice. The direction of the increase in size of a form- 
ing aneurism depends on its location. Constant pressure of the sac 
may overcome the resistance and cause absorption of the densest tissue, 
even bone. Hence aneurisms of the arch of the aorta may rupture 
externally or erode the vertebral column. 

The question as to the etiology T of aneurism is much debated. My 
own statistics on this subject confirm the opinion that syphilis is a fre- 
quent cause, especially in the early stages before marked arteriosclerotic 
changes have taken place in the arteries. This view is also supported 
by the fact that animals are rarely affected with aneurism. The experi- 
mental production of aneurism in animals by alcohol, trauma, etc., 
affords an interesting field for future investigators. 



CHAPTER IX 

EXAMINATION OF THE PLEUR^ LUNGS, AND UPPER AIR-PASSAGES 

The general condition of the pleurae and the exterior of the lungs 
having been noted when the thorax was opened, a minute examination 
of the serous surfaces and of the lung tissue is next made. As a prac- 
tical point it is well to remember that serous membrane when normal 
is barely visible to the naked eye, being smooth and glistening, but when 
inflamed its appearance depends upon the nature of the inflammation; 
the membrane will then be found roughened and more or less opaque, 
especially if examined by an oblique light. The extent of this condition 
should be noted as well as the character of the exudates. 

To remove the lung the left hand, palm inward, is introduced along 
the costal curve until the upper lobe can be elevated without undue 
pressure upon the pulmonary tissue. Should there have been no antece- 
dent inflammation, this procedure is readily accomplished, but some- 
times, when the adhesions are very strong and cannot be broken down 
by the hand, it may be necessary to dissect away the costal pleura and 
even the ribs and remove them along with the lung. When this condi- 
tion is found in the performance of routine postmortems, the examina- 
tion of the affected lung may be accomplished by making the incisions 
while the organ is still in the body. The upper lobe is now carried away 
from the median line of the body, anteriorly and downward, thus 
exposing the structures forming the root. Then, separating the index 
and middle finger of the left hand, the root of the lung is surrounded 
so that the upper lobe rests on the palm. In this way pressure can be 
made downward and away from the spinal column. Next, a perpen- 
dicular incision should be made in the direction of the spinal column 
and the bronchus severed. The advantage of this procedure is that it 
enables the operator to observe the character of the fluid in the bron- 
chus, avoiding its (otherwise very probable) contamination with blood 
When the character of- the fluid is noted, the rest of the structures may 
he severed with a few horizontal incisions, care being taken to avoid 
cutting the aorta and the oesophagus. It is well to remember when cut- 
ting these vessels that the left bronchus, which is considerably longer 
than the right, is situated below the pulmonary artery, while the right 

93 



94 POST-MORTEM EXAMINATIONS 

undivided bronchus is entirely above the right pulmonary artery. The 
left lung should be removed first, and, as it has usually two lobes while 
the right has three (I have seen this condition reversed but twice) , there 
is no necessity of adopting any method of distinguishing them after 
they have been removed from the body. Then, too, the left lung has a 
depression in its anterior border for the apex of the heart, it is longer 
and narrower than the right, not quite so heavy, and, as already stated, 
the arrangement of the bronchus and artery is different on the two 
sides. If, however, it is deemed necessary to do this, a single cut in 
the apex or bronchus of the left lung and two in the right will afford a 
ready means of distinguishing the one from the other. Examine the 
visceral pleura for fibrinous deposits, exudates, adhesions, etc. ; note 
the color, which varies with the age, the quantity of contained blood 
and air, minute hemorrhages, excessive pigmentation, cicatrices, spic- 
ules of bone, emphysematous spots, miliary tubercles, calcified tubercles 
with cheesy interiors, nodules, patches of consolidation, hemorrhagic 
and anaemic infarcts, tumors, etc. The lungs should be weighed at this 
time, before they are opened for further study. 

Placing the lungs upon their posterior surface on a board, rather 
than upon the more slippery stone table, the lower lobe of one lung is 
grasped with the thumb, the remaining fingers seizing the upper lobe ; 1 
in this way the organ is firmly held (Fig. 71 ) . With a single stroke an 
incision should be made from apex to base, commencing at the lateral 
convexity and passing to the entrance of the large vessels in the direc- 
tion of the bronchi, the lung being laid open like a book (Fig. 72)- 
In the case of the left lung the base will be turned towards the operator, 
while in the right it will be the apex, requiring an extra incision to open 
the middle lobe. Immediately note the color of the cut surface. The 
normal color without blood is light gray, while with different quantities 
of blood the shade ranges from light red or brick-red to dark, black, 
or blue-red. In heart disease the color of the pulmonary tissue is brown ; 
in anthracosis it is black. The amount of hypostatic congestion and the 
character of the fluid which exudes on squeezing are now determined. 
A microscopic examination of the scraping may be made. Next it is 
necessary to examine the substance of the lung for cavities, to observe 
the shape and position of areas of consolidation, and to ascertain the 

1 If the index-finger is introduced into the fissure between the lobes (and this 
method holds the lung very securely), care must be taken not to cut the finger in 
the subsequent procedures. 




Fig. 71.— Method of opening the lung. The organ, lying on its posterior surface, is held steady by 
slight pressure with the left hand on its upper portion, while a long, clean cut is made from the apex to 
the base of the lower lobe. 




Fig. 



72. — Lung laid open for minute inspection. The lung from this case was emphysematous 
and showed bronchiectasis. 




Fig. 73. — Method of opening the pulmonary blood-vessels. 




















































-1 








m- 


Jd tr ^ 


ji^lliBl 


Iv 




TV- 


4 


■ T| 








PHI 


Jt3^'. - 


p 


r 







Fig. 74. — Method of opening the bronchi. 



EXAMINATION OF PLEURA, LUNGS, AND AIR-PASSAGES 95 

specific gravity of consolidated areas in cold water. In pneumonic cases 
the entire lung may be placed in water to determine the portions con- 
taining air. A hemorrhagic infarct or a portion of apoplectic lung will 
sink in water, as well as the lung of croupous pneumonia. 

Now is the time to open the pulmonary vein (Fig. 73), artery, and 
bronchus (Fig. 74) with scissors. Parallel or transverse incisions may 
be made, but care should be taken not to make them so deep as to 
detach any portions of the lung. 

In order to obtain more room for the examination of the abdominal 
cavity, the attachments of the diaphragm to the ribs on the right side 
may now be severed, and the liver rolled over into the thorax. This 
gives the additional advantage of supplying a more favorable oppor- 
tunity for the subsequent inspection of the gall-bladder, biliary ducts, 
and portal vessels. 

It is frequently advisable to excise as one piece the tongue, oeso- 
phagus, thyroid gland, trachea, epiglottis, etc., so that a minute exami- 
nation of these parts may be made while they are exposed to good light 
in a convenient situation. For this purpose, in those cases where dis- 
figurement of the body is of no importance, the primary incision over 
the thorax may be extended up to the symphysis mentis and the parts 
dissected out with ease. Orth's method of doing this is as follows : 
Having made the primary incision to the chin early in the operation, 
the skin is reflected. Then by the use of the cartilage-knife an incision 
is made into the mouth at one angle of the jaw, cutting with a sawing 
motion to the chin and then back on the other side to the angle of the 
jaw, severing the geniohyoglossus muscle. The tongue, after being 
separated from the jaw, is pulled down with the forceps; after which 
the soft palate should be separated from the hard by the use of a knife, 
including in the operation the tonsils. A cut should now be made as 
high up as possible to remove the pharynx, tongue, and oesophagus from 
the spinal column and the deep pharyngeal muscles. This should be 
done with small perpendicular incisions on the spinal column through 
the retropharyngeal and retro-cesophageal tissue. These parts may be 
removed, however, without the incision being extended to the chin, as 
by careful manipulation the hand can tear the skin anteriorly away 
from its attachments by working from beneath, and a knife may be 
introduced into the centre of the tongue (through the geniohyoglossus 
muscle) posterior to its fraenum, thus leaving the tip in situ in case an 
examination of the mouth is to be made. (Fig. 75.) By a circular 



9 6 POST-MORTEM EXAMINATIONS 

incision of the muscles, fasciae, etc., with the knife beneath the skin, 
keeping as close as possible to the bony walls of the jaw, to the carotids, 
the bodies of the vertebrae, pharynx, and larynx, the treachea and oeso- 
phagus may be separated, drawn forward and downward, and removed. 
The tonsils are either torn out bodily with the fingers from below, or 
else incised while in the body and examined from above or below by 
reflected light. The edges of the tongue may be examined for injuries, 
such as wounds made by the teeth during a fatal convulsion. The 
mucous membrane is flattened in syphilis, and the tongue may be the 
seat of lymphangioma. The vessels of the arm should now be cut and 
the arch of the aorta severed from the oesophagus and bronchi. The 
whole aorta may be examined later or, if it is deemed better, this vessel 
as far as the diaphragm can be removed with the oesophagus. The 
latter procedure is particularly useful when disease of the oesophagus 
is suspected. The aorta is from seven to eight centimetres in diameter 
at its commencement and gradually narrows to forty-five or even thirty- 
five millimetres in the abdominal cavity. The oesophagus and the 
trachea are preferably opened up posteriorly throughout their entire 
extent. (Figs. 76, JJ, 78, and 79.) Carefully examine the vocal 
cords ; see if there are any tumors, syphilitic or tubercular ulcerations, 
inflammation, malformations, foreign bodies, diphtheritic membrane, 
etc. The oesophageal veins frequently carry on a large part of the col- 
lateral circulation in cirrhosis of the liver, and the rupture of one of 
these veins may cause death from hemorrhage, much blood being found 
in the intestinal tract. 

The examination of the vessels of the neck in cases of strangula- 
tion, as by hanging or otherwise, is of great importance. For this pur- 
pose the incision behind the ear made for the removal of the brain may 
be extended down the neck and the skin, fat, and superficial fascia of 
the face dissected away, thus making easy the exposure of the jugulars, 
carotids, etc. The tearing of the intima of the carotid indicates hang- 
ing or strangulation ; marks produced by pressure of the rope in the 
form of parchment-like skin at the sides of the neck and hemorrhages 
into the tissues are also found in hanging. Emboli of the carotid may 
cause sudden death, and thrombophlebitis of the jugular in cases of 
thrombosis of the lateral sinus is to be searched for. Aneurisms are 
sometimes seen. Hemorrhage into the sympathetic may occur in cases 
of fever with delirium and of heat-stroke; pigmentation and fatty 
changes take place in the cachexias and in fevers. 




Fig. 75. — Method of removing- tongue, tonsils, oesophagus, bronchus, etc., in a single piece, without 
incising the skin more than is done in the primary cut. 




Fig. 76. — Method of opening the oesophagus. The incision starts from below and extends upward 



Palatine arch incised 
Tonsil 



Thyroid gland 

Carotid artery 
Left subclavian artery 

CEsophagus laid open 



Aorta 




Palatine arch incised. 

Tonsil 

Uvula 



Thyroid gland 

Carotid artery 

Rigrht subclavian arterv 



Aorta 

Right bronchus 

Peribronchial lymph glands 



Fig. 77. — Examination of the organs of the neck. The arrows show the direction in which the incisions 
in the tongue and in the posterior wall of the oesophagus are to be made. (After Nauwerck.) 





Fig. 78. — Method of opening trachea. The incision starts from above and extends downwards. 







1 




Fig. 79. — Examination of trachea and vocal cords. 



CHAPTER X 

DISEASES OF THE LUNGS, PLEURA, AND ACCESSORY PARTS 

Abscesses. — Many varieties of bacteria have been found in pulmo- 
nary abscesses, such as pneumococci, tubercle bacilli, gonococci, actino- 
mycetes, and various pyogenic micro-organisms, (a) Solitary abscesses 
of the lung are comparatively rare. They are usually the result of ex- 
tension from neighboring parts, as the pleura, liver, or mediastinum. 
The abscess is encapsulated and contains a greenish-yellow pus, which 
often has an offensive odor, (b) Multiple abscesses are common in 
pyaemia. They are generally superficial, frequently wedge-shaped, and 
rarely encapsulated. They are at first firm, grayish red in color, and 
surrounded by a zone of hyperemia. Later they become distinctly 
purulent. The pleura is usually covered with a greenish lymph. Per- 
foration of the pleura, causing pyaemia, may occur. Septic pleuritis 
may be found associated. I have often seen such abscesses having their 
origin in a septic condition following criminal abortion. 

Asthma and Hay Fever. — Conditions characterized by attacks 
of dyspnoea, due to spasmodic contractions of bronchial tubes and air- 
vesicles. They are more frequent in males, and are due to spasm of the 
bronchial muscles and hyperemia of the bronchial mucous membrane. 
Attacks are induced by certain localities, odors, pollen of flowers, dust, 
etc. Lesions are not marked. There are hypertrophy and widening of 
the bronchial tubes, with thickened mucous membranes. Emphysema 
of air- vesicles. Chest is barrel-shaped; dorsal spine may be curved. 
Charcot-Leyden crystals and Curschmann's spirals are often found in 
the sputum. 

Atelectasis. — Collapse of the lung may be partial or total. It 
may exist in the foetus at birth or be caused by closure of the bronchi, 
capillary bronchitis, compression as from tumor, diaphragmatic hernia, 
pleuritic transudates and exudates, and marantic conditions, which lat- 
ter state of affairs is due to weakness, is most marked in the smaller 
ramifications of the lower and posterior bronchi, and often ends by sub- 
sequent oedema in pulmonary splenization. Any air remaining in the 
shut-off portion is absorbed, and the airless portion on section is dark 
red or bluish red. 

7 97 



98 POST-MORTEM EXAMINATIONS 

Bronchiectasis. — Dilatation of the bronchi, the result of various 
diseases of the lungs and bronchi. Etiology. — (a) Neighboring bron- 
chus may not be patulous or its own alveoli may be closed (includes 
atelectatic bronchiectasis), (b) Puckering of the peribronchial or in- 
terstitial fibrous tissue, (c) Parenchymatous change, as after chronic 
bronchitis, (d) Circumscribed narrowing, as from tumors, etc. Clas- 
sification. — (a) Cylindrical or uniform, (b) Saccular, spherical, or 
ovoid. ( i ) Dilatation of the bronchial tubes may be local or general. 
A number of sacculi are found opening one into another; these vary 
considerably in size; they have smooth walls covered with epithelium 
(mucous membrane), but may in dependent portions show ulceration 
which is prone to set up a fatal gangrene or a tuberculous lesion may 
develop. Sometimes the sacs are large and situated immediately be- 
neath the pleura. Putrefaction frequently follows the retention of 
material in them, causing a putrid bronchitis. (2) The lungs usually 
show marked fibroid changes, though these may be slight. The air- 
vesicles are sometimes emphysematous or condensed by pressure. (3) 
Adhesive pericarditis may follow extension of inflammation from 
pleura. (4) The liver usually shows chronic congestion; it may be 
fatty. 

Bronchitis. — Inflammation, acute or chronic, affecting the bron- 
chial tubes, but not involving the terminal bronchi. I. Acute. — (a) 
Infectious fevers, (b) Exposure, (c) Irritant gases and vapors, (d) 
Extension of inflammation from neighboring organs. II. Chronic. — 
(a) Certain occupations (stone-cutters, etc.). (b) Old age. (c) Sapro- 
phytic and other micro-organisms, (d) Repeated attacks of acute bron- 
chitis. Classification. — I. Acute. — (a) Catarrhal, (b) Suppurative, 
(c) Croupous. II. Chronic. — (a) Hypertrophic, (b) Atrophic or 
senile, (c) Putrid, (d) Plastic, (e) Tuberculous. I. Acute. — (1) 
In catarrhal inflammations the mucous membrane is thickened, swollen, 
may be hemorrhagic, and in early stages is covered with tenacious 
exudate. Later the exudate becomes thinner and purulent, and may be 
in quantities large enough to fill the large bronchi. If it extends to the 
small bronchioles it is called capillary bronchitis or preferably catar- 
rhal pneumonia. Lobular atelectasis surrounds the affected areas. (2) 
In suppurative bronchitis small abscesses, the result of septic embolism, 
are found in bronchial tubes. ( 3 ) Croupous bronchitis is characterized 
by the formation of a diphtheritic membrane, which sometimes forms 
complete casts of the smaller bronchi, but is not, as a rule, associated 



DISEASES OF THE LUNGS, PLEURAE, ETC. gg 

with the Klebs-Loffler bacillus. Bronchopneumonia is a frequent com- 
plication. II. Chronic. — ( I ) Hypertrophic. The whole lung is larger, 
firmer, and darker in color. The mucous membrane is thickened and 
often shows petechial hemorrhages. The whole bronchus is thicker and 
more fibrous ; its lumen is sometimes narrowed and may cause stenosis, 
sometimes dilated. The surrounding lung is usually emphysematous 
and shows increase of fibrous tissue. (2) Atrophic. Often the lung 
appears smaller, also lighter in weight and color. Its elasticity is im- 
paired, and it feels " cottony'' to the touch. There may be increase of 
connective tissue, but the mucous membrane is smooth, atrophied, and 
the lumen of the tubules may be widened. (3) Putrid. This is practi- 
cally a bronchiectasis. The bronchi are dilated ; their walls are usually 
smooth, but frequently show ulcerations, with fatty plugs and purulent 
masses such as are found in the sputum during life. Purulent oedema 
of lung is more or less general. (4) Plastic (fibrous). A chronic 
form of " croupous," occurs only rarely and is paroxysmal. The mem- 
brane is a fibrous, fairly consistent pseudomembrane about two milli- 
metres thick. There is no epithelium under it. The mucous surface 
is hyperaemic and infiltrated with cells. The thick ducts of the glands 
push the fibrous tissue off and it is coughed up. The smaller bronchi 
show catarrhal inflammation, but no membrane. (5) Tuberculous. 
This may be acute, but usually manifests itself as a part of a diffuse 
caseous process or as tuberculous ulcerations resembling those of the 
larynx. The right ventricle is hypertrophied in chronic bronchitis. 
(6) Cheesy bronchitis. The catarrhal secretion remains in the lumen, 
becomes thicker, and caseates. The mucous membrane becomes infil- 
trated with cells and these subsequently undergo caseation. (7) Gan- 
grenous. Often associated with bronchiectasis. 

Circulatory Disturbances. — Anaemia, brown induration, 
oedema, hemorrhages, infarcts, fat embolism, or even air embolism of 
the lungs may be associated with a similar condition in the right heart. 
A number of fatal cases of pulmonary embolism have followed intra- 
muscular injections of calomel for syphilis. Fat embolism should 
always be thought of in cases of fractures or of extensive injuries to 
the subcutaneous fatty- tissues. Haemoptysis may occur from hemor- 
rhagic infarcts, brown induration, tuberculosis, an aneurism rupturing 
in the trachea or bronchi, acute inflammations, purpura, scurvy, etc. 
It is interesting to note that a pulmonary hemorrhage in tuberculosis 
may be the beginning of an attack or precede a fatal termination. 

L.ofC. 



100 POST-MORTEM EXAMINATIONS 

Congestion, Passive. — This condition occurs where there is ob- 
struction of the circulation, especially in chronic illness requiring the 
recumbent position and in diseases of the central nervous system, (a) 
In mechanical congestion there is obstruction to the return of the blood 
to the heart. The lungs are voluminous, russet-brown in color, and 
cut and tear with difficulty. On section they are of a maroon tinge, 
which soon gives place to a vivid red on exposure to the air. (b) In 
hypostatic congestion the bases of the lungs are deeply cyanosed, the 
posterior parts particularly are engorged with blood and serum, and 
in some instances portions of the tissue will sink in water. In pro- 
longed coma the hypostatic congestion may be associated with patches 
of consolidation due to the aspiration of food into the air-passages, 
(c) In cerebral apoplexy the bases of the lungs are deeply engorged 
and heavy and on section exude a bloody serum. This congestion is 
most marked in, and may be confined to, the paralyzed side. 

Emphysema. — The dilatation of the air-vesicles is due to some 
weakening of the lung structure and a dilating force, usually expira- 
tion. It may follow chronic cough, certain occupations, as glass- 
blowing, senile changes, traumatism, albinism, congenital absence of 
elastic tissue, and atrophy of the diaphragm. The thorax is increased 
in its anteroposterior diameter and barrel-shaped. The clavicles are 
prominent, as are also the sternum and the costal cartilages. The inter- 
costal spaces are enlarged and the sternal fossa is deep. The neck 
appears to be shortened. Dilated veins may be seen along the line of 
the attachment of the diaphragm. The back is rounded and the curve 
of the spine increased. On removing the sternum, the anterior medias- 
tinum is found to be completely occupied by pulmonary tissue and the 
pericardial sac may be entirely covered by the lungs. The latter are 
large, light in color, and only slightly pigmented. They are inelastic 
and do not collapse, but pit readily on pressure. The edges are dis- 
tinctly rounded and obtuse. Beneath the pleura, especially about the 
anterior margins and the inner surface of the lobe near the right, 
enlarged air- vesicles of a delicate bladder-like appearance may be seen, 
varying in size from that of a pea to a hen's tgg (bullous emphy- 
sema). To the touch the sensation is soft like that of feathers, and 
when the air is removed a crackling sound is made and a paper-thin 
tissue is all that remains. The chief seats are at the edges and the 
apices. The mucous membrane of the large bronchi may be rough and 
thickened; bronchiectasis may also be present. The right heart is 



DISEASES OF THE LUNGS. PLEURJE. ETC. IO i 

dilated and hypertrophied ; the pulmonary artery may be enlarged and 
show atheromatous changes. Emphysema may be vesicular, where the 
air is confined within the dilated alveolar spaces, " or it may be inter- 
stitial, the alveolar walls being broken. The latter condition is seen 
especially beneath the visceral pleura and may be produced post mortem 
by decomposition. 

Gangrene. — Gangrene may be circumscribed or diffuse. The 
lower lobe is usually affected, the peripheral portions rather than the 
central. The gangrenous part is larger, heavier, and of an ash-gray to 
greenish-black color. The outer tissues are intensely cedematous, next 
is an area of deep congestion, and then a cavity with shreddy, irregular 
walls containing a greenish fluid. The pleura may be simply inflamed 
and contain an abnormal amount of exudate, or it may be perforated, 
causing a pyopneumothorax. The gangrenous material gives rise to an 
intense bronchitis, the bronchial tubes containing a thin, highly offensive 
pus. The elastic threads disintegrate later than the remaining tissue 
and this fact is of considerable diagnostic value. Embolic processes 
are common, abscesses of the various organs, especially the brain, being 
the result. The odor accompanying the softening and death of pul- 
monary tissue is seldom absent and is usually most offensive. This con- 
dition is called pneumomalacia and may be due to emboli. The mucus 
in the bronchial tubes may contain fatty acids, tyrosin, and leucin. A 
bacillus is supposed by some to be the cause of the gangrene. 

Goiter. — Hypertrophy of the thyroid gland. The etiology is un- 
known, but certain countries and localities seem to predispose. The 
glandular involvement may be local or general, the disease being char- 
acterized pathologically by the variety of the morbid changes. In the 
same gland may be found cystic disease, with mucoid, fatty, and colloid 
degenerations. The gelatinous or colloid change is the most important. 
On section the gland appears as a yellow or brownish mass, through 
which are scattered areas of colloid, in size from a pin-head to a millet- 
seed or even larger. In cystic goiter there is a distinct limiting mem- 
brane, brownish red if the cyst be due to hemorrhage. If slender 
masses of tissue project from this membrane, the condition is known as 
papillary cystadenoma.' In some cases the enlargement of the gland 
may be due to marked vascular dilatation without the formation of 
new gland-tissue. When the arteries only are dilated, Orth calls it 
struma aneurysmatica ; if the veins only, struma varicosa. Fibroid 
and calcareous changes are also common. 



IQ2 POST-MORTEM EXAMINATIONS 

Goiter, Exophthalmic (Basedow's or Graves's Disease). — 
A disease of doubtful origin, characterized by symptoms referable to 
the eye, the thyroid gland, the heart, and the nervous system. It is 
more common in females and during early adult or middle life. Hyper- 
trophy of the thyroid gland is rarely as great as in ordinary goiter. It 
may be diffuse or unilateral. There is a marked increase in the number 
and size of the blood-vessels and an absorption of the colloid material, 
which is replaced by a more mucinous fluid. One or both eyes show 
undue prominence, probably due to increase of the orbital fat. The 
thymus gland is persistent and enlarged, and there is an increased 
amount of connective tissue in the neck. Pigmentation of the skin may 
be marked and simulate Addison's disease. Myxoedema may develop 
in the later stages. Emaciation may be extreme. Glycosuria and albu- 
minuria are not infrequent. The heart is usually hypertrophied ; it 
may be dilated or even normal in appearance. 

Hemorrhage, Pulmonary, or Apoplexy. — This is a condition 
in which there is hemorrhage into the air-cells and lung-tissue. The 
lung is large, firm in consistency, dark in color, and heavy. On section 
there is extravasation of considerable amounts of fluid blood, usually 
more or less frothy. The extent of lung involved differs very greatly. 
The hemorrhage may be due to thrombosis or aneurism of the pul- 
monary artery or to aspiration, as in gangrene and tuberculosis, and 
may occur in the hemorrhagic diathesis. 

Infarcts. — Notwithstanding its ample collateral circulation, the 
lung is frequently the seat of small or larger infarcts, especially of the 
hemorrhagic variety. They are usually associated with brown indura- 
tion. The embolus may come from a marantic clot in the right heart, 
and in some cases may be infected with pyogenic organisms. 

Laryngitis, (Edematous. — (a) Septic infection, (b) Trauma- 
tism, (c) Certain drugs. (d) Chronic visceral diseases, — e.g., 
Bright's disease. Classification. — (a) Inflammatory, which may be 
septic or non-septic, (b) Non-inflammatory or dropsical, (i) The 
aryepiglottic folds and the ventricular bands are the parts chiefly 
affected. The vocal cords are seldom included, but the oedema may go 
below them. (2) The exudation may be serous, seropurulent, or puru- 
lent, and may or may not be blood-stained. (3) In very severe cases 
the larynx may be entirely closed. 

Pleurisy. — This condition is due to exposure to cold and wet, 
traumatism, extension of inflammation from neighboring organs, pyo- 



DISEASES OF THE LUNGS. PLEURA, ETC. 103 

genie micro-organisms, many infectious fevers, infectious granulo- 
mata, or malignant tumors. Classification. — I. Acute, (a) Serous, 
serofibrinous, fibrinous. (b) Purulent. (c) Hemorrhagic. II. 
Chronic, (a) Pleurisy with effusion, (b) Dry pleurisy, (c) Primi- 
tive dry pleurisy. 

I. (a) In acute pleurisy the serous, serofibrinous, and fibrinous 
differ in the character of the exudate. In all three the serous membrane 
is at first red, sticky, and lustreless; later it becomes somewhat pale, 
thickened, and roughened. The pleural cavity may contain a liquid 
inflammatory exudate varying in amount from a few cubic centimetres 
to one or more litres. Its specific gravity is above 1017; it is rich in 
fibrin and contains many leucocytes and some red corpuscles and swol- 
len endothelial cells. The serofibrinous exudate contains more fibrin 
and less fluid. The characteristic of the fibrinous exudate is the so- 
called bread-and-butter appearance. The fibrinous deposit varies in 
thickness from a millimetre to a centimetre or more, (b) Purulent 
pleurisy may follow the other acute forms or may be primary. The 
serous membranes are covered with a creamy exudate and the pleural 
cavity contains from a few cubic centimetres to a litre or more of pus. 
This is of a greenish-yellow color, often has an offensive odor, and is 
frequently associated with tuberculosis of the membranes, (c) Hemor- 
rhagic pleurisy may be due to asthenic conditions — tuberculosis, cancer 
— or may occur in perfectly healthy individuals. In the latter case it 
must be remembered that during aspiration the lung may be wounded 
and any fluid present may thus become mixed with blood. The pleural 
cavity contains blood, which is usually in a fluid condition varying con- 
siderably in density. The serous membranes are generally inflamed 
and stained with blood-coloring matter. II. (a) Chronic pleurisy 
with effusion may persist for months without undergoing alteration. 
The post-mortem appearances are very similar to those of an acute 
pleurisy, (b) Chronic dry pleurisy is the result of an acute pleuritis 
in which the exudate is partially absorbed and the material remaining 
undergoes organization. This occurs usually at the base and may cause 
marked flattening of the chest. Small pockets of fluid are often found. 
The lung itself is compressed, airless, and fibroid. It is frequently 
impossible to separate^the layers of pleura, (c) Primitive dry pleurisy 
may be limited in extent or universal. The layers of pleura are firmly 
adherent to one another and, especially about the lower lobe, are much 
thickened. In cases of tuberculous origin they present fibroid masses 



I04 POST-MORTEM EXAMINATIONS 

and small tubercles, and between the layers is a reddish-gray fibroid 
tissue, sometimes infiltrated with serum. Dry pleuritis may be unilat- 
eral or bilateral, and may be accompanied by a similar condition of the 
pericardium and peritoneum. The bronchi may present marked dila- 
tations and the lung tissue is more or less sclerosed. In diaphragmatic, 
encysted, and interlobar pleurisy the morbid anatomy is similar. 

Pneumonia. — We may distinguish various forms of pneumonia 
as catarrhal (bronchopneumonia), chronic interstitial, and lobar 
(croupous or fibrinous). In cattle there is also found a very infectious 
variety known as pleuropneumonia. Catarrhal pneumonia is an acute 
(and also chronic) inflammation of the lungs, involving both bronchial 
tubes and air- vesicles, due to aspiration of irritants. It arises from : 

(a) Micro-organisms, — e.g., Diplococcus pneumonia;, staphylococci, 
streptococci, the diphtheria bacillus, and the bacillus of pneumonia. 

(b) Inhalation of irritant gases and vapors, (c) Infectious fevers. 
(d) Extension of inflammation from neighboring parts. Macroscopi- 
cally the lung is larger, heavier, and firmer to the touch. On section 
the surface is somewhat dark red in color, but distinctly mottled, and 
may drip blood. On palpation nodular bodies can be felt, surrounded 
by crepitant areas. The nodules may resemble gray hepatization; 
typical ones contain a central bronchiole surrounded by a grayish-red 
elevated area of consolidation and filled with tenacious purulent mucus 
which can be pressed out. Minute hemorrhages are common in the lung 
and on the pleural surfaces. Emphysema is seen on the anterior and 
upper portions of the lung, especially within the inflamed areas. Fibroid 
changes seldom follow bronchopneumonia. 

Chronic interstitial pneumonia may be due to: (a) Various acute 
inflammations (rare). (b) Tuberculosis. (c) Chronic pleurisy. 
(d) Chronic poisoning, (e) Syphilis. The disease is usually unilat- 
eral ; the chest on the affected side is sunken, deformed, and the shoul- 
der depressed. The opposite side is usually emphysematous. On open- 
ing the chest the affected lung is seen to be airless, firm, hard, and very 
resistant to the knife. On section grayish fibroid tissue of variable 
amount, through which pass the blood-vessels and bronchi, is found. 
The latter may be more or less dilated. The unaffected lung is much 
enlarged and occupies the greater portion of the mediastinum. The 
heart is drawn over to the affected side. It is hypertrophied and there 
may be atheromatous changes in the pulmonary artery. Amyloid 
changes in the other viscera may be found. 



DISEASES OF THE LUNGS, PLEURyE, ETC. 



IO! 



Lobar pneumonia occurs in adult life, in males, in infectious dis- 
eases, in alcoholism, after exposure to cold and wet. The Diplococcus 
pneumonia of Frankel, or Streptococcus lanceolatus, is found in a 
large proportion of cases. It occurs in pairs surrounded by a lanceolate 
capsule. The organism is readily demonstrated in cover-glass prepara- 
tions stained by Gram's method. It is found in the bronchial secretions 
and in sections of the affected lung. The disease is divided into three 
distinct stages, — hyperemia, red hepatization, and gray hepatization. 
(a) In the stage of engorgement, which lasts about twenty- four hours, 
the lung is heavier, more solid, firmer, and redder than normal. The 
surface of section exudes fluid and serum. The lung still crepitates, 
though not so distinctly as the healthy tissue. The excised portions 
partially float, (&) In cases of red hepatization, which lasts from one 
to four days, the lung is still larger, heavier, firmer, and of a deep-red 
color. It is airless, does not collapse on exposure to the atmosphere, 
and excised portions sink in water. The surface of the lung is covered 
with a more or less extensive layer of fibrin, which forms a false mem- 
brane that contrasts markedly with the smooth shiny appearance of 
the unaffected portions of the lung. The surface may retain impres- 
sions of the ribs. On section the lung is dry and reddish brown. It is 
exceedingly friable. Careful inspection shows that the surface is dis- 
tinctly granular, the granules being due to fibrinous plugs, which can 
be scraped off with a knife together with a reddish viscid serum. The 
plugs of exudate are lighter in color than the intensely red tissue. The 
smaller bronchi often contain fibrinous clots, which may also be found 
filling the blood-vessels at the root of the lung. The microscope reveals 
fibrinous threads, in the meshes of which are seen alveolar epithelial 
cells which have undergone hyaline and necrotic changes, leucocytes, 
red blood-cells, micro-organisms, etc. Sections taken from the central 
portion of the lung show more cellular elements, while those from the 
surface are richer in fibrin, showing that infection probably takes place 
from the bronchi. In this connection it is well to remember that there 
is a pneumonic form of plague and of several of the other infectious 
fevers, (c) In gray hepatization the color varies from a reddish brown 
to a grayish white. - The surface is more moist, the exudate more 
turbid. The granules, are less distinct and the lung-tissue is still more 
friable. The exudate is softened and the pneumococcus is usually no 
longer to be demonstrated. The cell-elements are disintegrated and 
prepared for absorption. Gray and red hepatization may coexist in the 



io 6 POST-MORTEM EXAMINATIONS 

same lobe. In advanced stages we may also have a purulent infiltration. 
Carnification may result. This is a productive inflammation, and the 
lung is an airless, firm, regular, gray or red mass. It is probable that 
in these stages resolution could not take place. Abscesses of varying 
sizes, however, may develop, and if found should always be searched 
for the detection of tubercle bacilli. 

Other Lesions in Croupous Pneumonia. — (a) Usually the right 
lung is affected, the process being confined to the lower lobe. The un- 
affected portions are congested and cedematous. (b) At the time of 
death the bronchi contain, as a rule, a mucous secretion tinged with 
blood, more rarely the tenacious mucus so. characteristic of pneumonic 
sputum. The mucous membrane is reddened, but not usually swollen. 
The affected areas and small bronchi contain fibrinous plugs, which 
may extend into the larger tubes and form perfect casts. The bronchial 
glands are swollen, soft, and hemorrhagic, (c) The pleural surface 
over the inflamed area shows a more or less extensive exudate, which 
may be serous or fibrinous. 

Lesions in Other Organs. — (a) The distention of the right heart 
is marked. The cavities are often distended with firm tenacious 
coagula. (b) In many cases the spleen is enlarged, (c) The kidneys 
show cloudy swelling and often acute parenchymatous changes, (d) 
Pericarditis is not infrequent; it is often associated with pneumonia 
of the left side or with double pneumonia, (e) Endocarditis is more 
common; it may be of a malignant type, (f) Meningitis, usually 
cortical, is not infrequent and is often associated with malignant endo- 
carditis, (g) The liver shows parenchymatous changes and often 
extreme engorgement of the hepatic veins. 

Complications. — (a) Pleurisy. (b) Empyema. (c) Pericar- 
ditis, most common in children, (d) Endocarditis is more frequent 
than pericarditis, (e) Myocarditis is rare. (/) Meningitis is per- 
haps the most serious complication, (g) Otitis media is not unusual 
in children. (A) Abscesses or gangrene in the lung occasionally occur. 
(i) Severe and often fatal toxaemia may develop with a comparatively 
slight lesion in the lung. ( /') Also in conjunctivitis, arthritis, etc. 

Terminations. — (a) Liquefaction, absorption, and resolution, (b) 
Suppuration, (c) Abscesses or gangrene, (d-) Fibroid changes or 
carnification. (e) Lymphangeitis and perilymphangitis may occur. 



DISEASES OE THE LUNGS, PLEURAE. ETC. 



107 



TABLE SHOWING 



DIFFERENCES BETWEEN 
CATARRHAL PNEUMONIA. 



CROUPOUS AND 



Croupous Pneumonia. 

1. Whole lobe usually affected ; hence 

the name lobar pneumonia. 

2. No areas of healthy lung tissue in 

affected lobe ; other lobes healthy, 
but may be congested, especially 
those near the affected lobe. 

3. Lung weighs much more than nor- 

mal. An entire lobe may sink in 
water. 

4. Microscopical appearance varies ac- 

cording to stage. Much fibrin ; 
hence the name fibrinous pneumo- 
nia for this condition. 



An extensive fibrinous exudate on 
the pleura covering the affected 
area; hence the name pleuropneu- 
monia for this affection. 

Pneumococcus found in nearly all 
cases. 

Usually at base and posteriorly. 



8. Usually one-sided. 

9. On section the lung varies according 

to stage, the marbled appearance 
being especially striking in the 
third stage. Notice the fibrinous 
plugs. 

10. Sputum, so-called rusty sputum. 

ii. Lung lesions of same age. 



Catarrhal Pneumonia. 

1. Lobules affected; hence the name 

lobular pneumonia. 

2. Irregular areas of lung tissue in va- 

rious stages of degeneration inter- 
mingled with normal lobules. 

3. Lung weighs but slightly more than 

normal. An entire lobe will float 
on water, though small portions 
may sink. 

4. Microscope reveals three zones : cen- 

tral, a small bronchus : middle, a 
desquamative area containing many 
cells, but little or no fibrin; outer, 
a zone of congestion. Hence, the 
synonym, bronchopneumonia. 

5. Exudate slight, if present. 



6. Pneumococcus rarely found. 

7. Usually at the termination of the 

smaller bronchioles and anywhere 
in the lung. 

8. Usually on both sides and associated 

with other diseases. 

9. On section the lung is congested. 

Small angular irregular patches, 
the central portion being the oldest, 
are seen. 

10. Sputum more purulent. 

11. Diseased portion of the lung varies; 

some spots are old, some are new, 
the oldest being around the bron- 
chioles ; healthy tissue between 
affected areas. Caseous pneumo- 
nia, really a form of catarrhal 
pneumonia, is due to the action of a 
toxin, as from the tubercle bacilli. 
In phthisis there may be small 
areas of croupous pneumonia. 

12. Capillary bronchitis and catarrhal 

pneumonia are. pathologically, 
practically the same. 



108 POST-MORTEM EXAMINATIONS 

Pxeumoxocoxiosis. — This is a fibroid condition of the lung often 
associated with tuberculosis, produced by the inhalation of particles 
of mineral or metallic substances. Various names have been applied 
to it, depending upon the nature of the inspired dust, — e.g., anthra- 
cosis, siderosis, calcicosis, lithosis, silicosis, etc. Occupations such as 
coal-mining, the manufacture of pottery, steel-grinding-, grindstone- 
making, tobacco-sorting, needle-grinding, etc., are conducive to this 
condition. Unless, as is frequently the case, emphysema coexists, the 
affected lungs are harder, firmer, and often smaller than normal. They 
are usually of a blue-black or a yellowish or buff color, and afford a 
striking contrast to the lung of a child. Even when the inspired dust 
is pale, the lungs are apt to be of a dark color. In advanced stages of 
anthracosis an ink-like juice may exude from the cut surface. In side- 
rosis, caused by oxide of iron, the lung is of a reddish color. On section 
condensed portions of highly fibroid tissue are seen. The surface of 
section commonly exhibits numerous raised points, which give it a 
coarse granular appearance. These raised points are found to be small, 
thickened, fibroid bronchial tubes protruding above the surface. The 
deposits are found microscopically everywhere along the course of the 
lymphatics. The signs of chronic bronchitis are present, though the 
mucous membrane of the bronchi remains unpigmented. The bronchial 
and peribronchial glands as well as the peribronchial lymph-nodules 
are frequently intensely pigmented ; usually pigmentation may be found 
also in the pleura, liver, and spleen. True osseous formations, coral- 
like in shape, may be found in the lungs. 

Pneumothorax. — This condition may be due to traumatism, 
tuberculosis of the lung rupturing into the pleura, other infectious 
granulomata, and malignant growths. The thorax is usually distended ; 
the intercostal spaces may be obliterated. The introduction of a trocar 
allows the escape of air. The pericardium and heart are pushed or 
drawn to the opposite side. The serous membranes are inflamed and 
a serous or purulent fluid is present. The lung is usually compressed 
and carnified and may be adherent to the chest wall at the apex. It is 
frequently the site of caseous nodules or cavities at the apex. 

Stomatitis. — (a) Extremes of life, (b) Most common in nursing 
children, (c) Irritant foods and poisons, (d) Extension of inflam- 
mation from the intestinal tract, (e) The infectious diseases (scurvy). 
Classification. — I. Acute, (a) Catarrhal, (b) Aphthous, (c) Vesi- 
culous (herpetic), (d) Ulcerative, (e) Gangrenous. (/) Infectious. 



DISEASES OF THE LUNGS, PLEURA, ETC. 109 

II. Chronic. ( 1 ) Catarrhal. The mucous membranes are swollen, 
hemorrhagic, and glazy in appearance. The follicles are often very 
prominent. There is desquamation of epithelium and sometimes small 
ulcers form. The submucous tissue may be involved. (2) In aphthous 
stomatitis the tongue, the cheeks, and the tonsils are principally 
affected. The mucous membrane is covered with small whitish pin- 
point elevations, which frequently undergo necrotic changes and show 
more or less superficial ulcerations. The lesion always starts as a 
vesicle. The surrounding mucous membranes usually show evidences 
of acute inflammation, although they may appear normal. (3) In 
ulcerative stomatitis the points of election are the gums, the lips, and 
the cheek in the line of the teeth. The ulcers are gray and linear, with 
sharply defined, red edges. In strumous children they show a marked 
tendency to affect the deeper structures, sometimes causing necrosis and 
suppuration of portions of the jaw. In severe cases where the alveoli 
are involved, the teeth may loosen and fall out. (4) Gangrenous 
stomatitis (noma) occurs between the ages of two and twelve years, is 
more common in girls than in boys, and follows infectious fevers (fifty 
per cent, of the cases occur after measles). It is characterized by the 
formation of a fungoid ulcer, beginning on the inner aspect of the 
cheek, usually with distinctly circumscribed, deeply congested edges, 
the surrounding tissues being markedly cedematous. The outer surface 
of the cheek is reddened, brawny, and indurated. The gangrenous 
ulcer has a decided tendency to spread, frequently involving the gums, 
cheek, tongue, and bones of the neighboring structures. Pneumonia 
not infrequently develops and is one of the causes of a fatal termination. 
Some recent investigators have found true diphtheria bacilli in the 
diseased area. That these organisms have an etiological connection 
with noma is confirmed by reports of cures after the use of the anti- 
toxin of diphtheria. 

Syphilis. — (a) In white pneumonia of the fcetus the affected lung 
is heavy and airless. On section it presents a grayish-white appear- 
ance, (b) Hereditary gummata are small in size, grayish in color, 
firm, and more or less symmetrically distributed throughout the lung. 

(c) Acquired gummata vary in size from a pea to a goose's egg. They 
are grayish yellow in color and are embedded in connective tissue. 
The parts around them are hard and brawny and of a glossy lustre. 

( d ) There may be a fibrous interstitial pneumonia in wdiich the lesions 
are hard, large, and pale or dark grayish red in color. The middle of 



IIO POST-MORTEM EXAMINATIONS 

the right lung or either apex is the part most frequently involved. 
(e) The pleura is thickened. (/) Endocarditis may extend to the 
hepatic artery and portal vein. The usual seat is at the hilum. Some 
of the cases described as being of syphilitic origin are nothing more 
nor less than a chronic interstitial tuberculous pneumonia. 

Tuberculosis. — I. Acute. (a) Miliary tuberculosis. (b) 
Phthisis florida. II. Chronic, (a) Ulcerative phthisis, (b) Fibroid 
phthisis. 

I. Acute. — (a) In acute miliary tuberculosis the lesions are usually 
present in both lungs, having been propagated by the pulmonary blood- 
vessels. They are frequently so small and transparent that they may 
be overlooked on macroscopic examination. At other times they are 
exaggerated in localized spots or even become diffuse. In the latter 
case the lung is increased in size, is firm in consistence, in color is a 
darker shade of red, is heavier, and crepitates, (b) Phthisis florida, 
or acute phthisis with formation of cavities, presents a varied appear- 
ance. One lobe or more or less of the whole lung may be affected. 
The organ is heavy; the implicated portions do not collapse and are 
firm and airless. The pleura is covered with a thin exudate. On section 
the condition may resemble red or gray hepatization or an intermediate 
stage between them. In other instances the lung presents a mottled 
appearance, some areas being intensely congested, others exhibiting a 
characteristic pale-gray gelatinous exudate, others caseous degeneration 
and not infrequently cavity formation. Recently affected areas of 
pulmonary tissue with croupous pneumonia are often seen. Such lungs 
readily caseate and produce ulcerative excavations of considerable size. 

II. Chronic. — (a) In ulcerative tuberculosis apical involvement 
in relation to implication at the base exists in the proportion of five 
hundred to one, according to Kidd. There are various lesions. First, 
there are caseous nodules, which are grayish, white, or yellow in color. 
Second, cavities may exist, which, if the case is acute, have walls made 
up of soft caseous masses. In the more chronic cases these walls are 
replaced by pyogenic membranes of greater or less density. Frequently 
trabecule are seen in the walls ; these are the blood-vessels which have 
resisted the tuberculous process. Third, pneumonic areas and evidences 
of chronic bronchitis are seen. Fourth, some thickening of the pleura 
is constant. This may be merely an acutely inflamed area rubbing 
against a corresponding area on the parietal pleura or it may be tightly 
adherent to it. Not infrequently perforation causes a pyopneumo- 



DISEASES OF THE LUNGS, PLEURAE, ETC. m 

thorax. Fifth, enlarged bronchial glands are discovered which are 
caseous and often pigmented. Lastly, the bronchi are thickened and the 
lumina of the smaller ones often obliterated. The larger tnbes show 
caseous deposits in the submucous and fibrous coats, (b) In fibroid 
phthisis the organ is permeated with interstitial overgrowth. In some 
cases the interstitial change is most prominent; in others the tuber- 
culous process is slightly more marked. The unaffected portions of the 
lung are very emphysematous and pigmentation is considerable. The 
right ventricle and sometimes the whole heart are hypertrophied. 

Tumors. — The benign tumors, fibroma, adenoma, and chondroma, 
and the malignant growths, both primary and secondary, are found in 
the lung, the first being rare, while the second are comparatively com- 
mon. Carcinoma may originate in the epithelium of the alveoli, the 
bronchi, or the mucous glands. Endothelioma starts from the lym- 
phatic apparatus. In primary growths one lung only is involved; in 
secondary growths, both lungs. Secondary cancer is more frequent in 
women than in men. These secondary growths may be scirrhous, ence- 
phaloid, epitheliomatous, or colloid cancer, or melanosarcoma. In 
malignant diseases of the lungs pleurisy, generally of a hemorrhagic 
type, is commonly present. The tracheal or bronchial glands are 
usually the seat of metastatic growths. The condition is most common 
in middle life. Dermoid cysts are found, but very rarely. 



CHAPTER XI 

CRITICAL EXAMINATION OF THE ORGANS OF THE ABDOMINAL CAVITY 

THE OMENTUM AND PERITONEUM. 

Having thoroughly examined the omentum during the general 
inspection of the abdominal cavity, it may now be removed therefrom 
and any abnormalities or pathological lesions studied and described, 
though, as a rule, I prefer to make this examination in the body, and 
to remove the omentum afterwards along with the transverse colon. 

Cancer of the peritoneum is found: (a) Female sex. (b) Age 
from forty to sixty years, (c) Heredity, (d) Secondary to cancer of 
stomach or ovaries most often. It is almost always secondary. Often 
spoken of as " miliary carcinosis," because nodules are small, spherical, 
and diffuse. The serous membranes are pale, thickened, with marked 
fibrinous deposits, which form adhesions to neighboring viscera; the 
omentum is indurated and forms a mass transversely across the abdo- 
men; the bowels are often firmly matted together. Ascites is usually 
present ; the amount of fluid may be only a few ounces or several pints. 
In some cases of colloid cancer the masses are of large size. 

Acute general peritonitis is due to : (a) Exposure to cold and wet. 
(b) The following micro-organisms have been found: Streptococcus 
pyogenes, Bacillus coli communis, Staphylococcus aureus, Streptococ- 
cus lanceolatus, Bacillus proteus, and B. pyocyaneus; rarely, the gono- 
coccus in the female and anthrax and typhoid bacilli, (c) Perforation 
of the bowel. Classification. — (a) Serous, (b) Serofibrinous, (c) 
Fibrinous, (d) Purulent. (e) Putrid. (/) Hemorrhagic. (g) 
Ulcerative. In acute general peritonitis the peritoneum has lost its 
lustre, is opaque, and is covered with an exudate varying with the type 
of the disease. The intestinal coils are distended and glued together 
with lymph. They are more or less displaced and compressed and their 
walls are easily torn. The serous membrane may be easily separated 
from the muscular coat. In peritonitis due to perforation the perito- 
neum and its contents are discolored by the faeces, while the peritoneal 
cavity contains gas, which escapes with a hissing noise when it is 
opened. 

Chronic peritonitis : (a) Follows acute, (b) Tuberculosis, (c) 

112 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS 



113 



Extension of inflammation from the abdominal organs, (d) Cancer. 
Classification. — (a) Local adhesive, (b) Diffusive adhesive, (c) Pro- 
liferative, (d) Hemorrhagic. (1) Localized peritonitis occurs about 
the spleen, liver, intestines, mesentery, and pelvic organs. Bands of 
connective tissue more or less firmly organized bind the various organs 
together, producing marked alterations in appearance and position of 
the parts. The peritoneum is thickened and puckered. (2) Diffuse 
adhesive peritonitis follows acute inflammation, either simple or tuber- 
culous. The abdominal cavity is often obliterated ; the intestinal coils 
are firmly matted together by the plastic exudate, which becomes event- 
ually converted into bands of fibrous tissue. The liver and spleen are 
usually involved in the adhesions. (3) In the proliferative form there 
is great thickening of the peritoneum, which is opaque and white in 
color. The omentum is usually rolled into a thick mass between the 
stomach and the colon. The liver and spleen are the subjects of a 
chronic capsular inflammation; both are usually smaller in size, with 
thickened, wrinkled capsules. There are seldom many adhesions, and 
serous effusion may be present in the abdominal cavity. The intestinal 
wall is greatly thickened and the mucous membrane of the ileum is 
thrown into folds. Nodular thickenings may be present and be mis- 
taken for tubercles. (4) The hemorrhagic form occurs particularly in 
cancerous and tuberculous conditions. Layers of new connective tissue 
form on the surface of the peritoneum ; they contain large blood- 
vessels, from which the bleeding occurs. It is commonly a circum- 
scribed process. Orth compares it to chronic internal hemorrhagic 
pachymeningitis. 

THE SPLEEN. 

The spleen varies greatly in size and weight, even during health 
and in the same individual at different times. I have removed a spleen 
which weighed only one hundred and eighty-six and one-half grains 
(senile atrophy) and another weighing over seven pounds (malarial 
enlargement). The normal weight is about five ounces and the meas- 
urements are five by three by one and one-fourth inches. The spleen 
may now be removed from the abdominal cavity, though some patholo- 
gists recommend its excision later in connection with the pancreas. It 
is easily found by passing the hand along the left under surface of 
the diaphragm from the eighth to the eleventh rib, well towards the 
side and beneath the cardiac end of the stomach. Usually but little 



H_|. POST-MORTEM EXAMINATIONS 

force is necessary to bring it into view, with the gastrosplenic omentum 
and splenic artery and vein still intact. These parts are then cut or 
torn with a sort of twisting movement. In some cases the spleen 
is so soft that lacerations may be made in its substance by the fingers. 
These should not be mistaken for traumatic rupture of the organ or 
for the rupture that sometimes, though rarely, results from disease. 
Occasionally the spleen is absent. Before detaching it examine the 
course of the splenic artery for aneurisms, supernumerary spleens, 
enlarged glands, etc. When this has been done the artery may be 
divided and the organ removed from the body. Notice whether or 
not the capsule is normal or thickened ; it should be thin, smooth, and 
transparent. ' 

Lay the spleen on the table, fix it with the left fingers, and with 
one stroke incise it in its longest diameter. Other incisions transverse 
to the primary one may be made for further investigation. The color 
of the normal spleen is dark red, somewhat darker and of a bluish 
tinge in children ; it may be brownish, from the presence of hemo- 
siderin; or yellow, as in jaundice (or in the new-born, due to bilirubin 
crystals) ; or streaked with blue, ow T ing to the presence of melanin. 
Coal dust may be found in the spleen, having probably entered the cir- 
culation through the peribronchial glands. Hyperplasia of the fibrous 
stroma in cases of chronic enlargement of the organ, as in malaria and 
leukaemia, may give to the spleen a grayish tinge. 

The structure of the splenic tissue may then be examined, and the 
changes in the splenic pulp, the Malpighian bodies, and the connective- 
tissue trabecule noted. A disturbance of the local circulation may 
lead to various changes. Oligemia is marked by the pale light-red 
or grayish-red color of the spleen, with wrinkling of the capsule and 
prominence of the trabecule. Hyperemia due to congestion is char- 
acterized by an enlarged, hard, dark-red splenic pulp, with smooth 
surface on section and thickening of the capsule, trabecule, and vessel 
walls. Infarcts of the spleen are common, and are usually wedge- 
shaped, with the apex towards the hilum. They vary in size from that 
of a pea to that of a cherry and may at times include half of the spleen. 
Anemic infarcts are of a cloudy-yellow color, while the less common 
hemorrhagic infarcts are very dark red, and later become yellowish 
red, and even whitish yellow as the coloring matter of the blood dis- 
appears. Acute splenitis, resulting in the formation of pus, is not fre- 
quent. An acute productive splenitis, the cause of the so-called splenic 




Fig. 8i. — Method of removing the intestines. They are first tied in two places, a foot or so above the ileocecal valve. 




Fig. 82.— Bucket method of opening and cleansing intestines. 




o <u 
9 h 







2 E 



° s 
w r. 



° 5 

00 o 




bfl to "5j 



b o 



1) •_ _• 

-, « P 






CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS n^ 

tumor, is characterized by enlargement of the spleen, with the capsule 
markedly on the stretch, and the pulp on section being of a vivid red, 
at first darkish and later somewhat lighter. The pulp is soft and 
exudes so as to conceal the Malpighian bodies. Fibrous productive 
or chronic inflammation of the spleen causes the chronic splenic tumor, 
recognized by the large size of the organ, which is hard, of a light or 
dark brownish hue, with thickened trabecular, that may appear as 
streaks through the splenic substance. A leukaemic spleen is very hard 
and of a reddish-gray color ; it sometimes weighs over twenty pounds. 
Miliary tubercles, with caseation, and various tumors of the spleen 
should be noted. In the colored race miliary tubercles at times do not 
undergo caseation and may attain the largest size of any developing in 
the body. I have frequently seen them as large as wild cherries. The 
most important of all the forms of retrogressive disturbances of nutri- 
tion of the spleen is amyloid degeneration. In this disease the spleen 
is firm and inelastic, so that the pressure of the finger leaves a decided 
mark. Amyloid degeneration of the pulp is characterized by the 
smooth, shining, almost transparent appearance of the cut surface, 
while the so-called sago spleen — the amyloid degeneration of the Mal- 
pighian bodies — is recognized by the enlargement of the lymph-nod- 
ules, which on section appear somewhat transparent and scattered over 
the cut surface. The amyloid reaction would be more frequently dem- 
onstrated if Lugol's solution were applied as a routine practice. Ec- 
chinococcic cysts of the spleen are sometimes found. 

THE INTESTINES. 

AYhen the exudation in the peritoneal cavity is fibrinopurulent and 
has a fetid odor, its source should be sought in a perforation of the 
intestine, although it may originate elsewhere, as from the uterus and 
adnexa. The entire intestinal tract should be very carefully inspected, 
starting from below and going upward, and areas of adhesions very 
gently broken down, care being taken not to make an artificial opening, 
an accident quite apt to occur in certain diseased conditions of the 
bowels. A proper examination of the intestines can be made only 
after they have been removed from the body. For this purpose an 
opening is made in the mesorectum near the point of attachment of 
the gut, and with a loop of string carried under the nail of the index- 
finger (Fig. 80) the intestine is ligated in two places far enough apart 
to allow it to be divided between them (Fig. 81). According to Orth, 




Il6 POST-MORTEM EXAMINATIONS 

the lower end of the colon is used as the starting-point, and, according 
to Nauwerck, the transverse colon. After the bowel is cut, its proximal 
extremity is grasped and the mesentery is severed by a sawing or 
fiddle-bow movement close to its intestinal attach- 
ment along the whole extent of the colon and about 
a foot along the ileum. Here two more ligatures 
are applied and the intestine is severed between 
them; this portion is then removed to the sink or 
bucket and washed out, but the ileocecal region 
and its contents are to be examined before wash- 
ing. If a spigot is at hand, the upper end of the 
tube may be drawn over it and the water allowed 
to run through until clean. After examination of 
the matter washed out, the intestine is opened 
along its mesenteric border and the mucous mem- 
fig. 80. -Method of |3 rane inspected. The intestines are opened either 

passing the string through . 

an opening in the mesentery by pushing them into the open blades of the scis- 
previous to tying it. SQrs Q ^ better? by thrusting the enterotome or scis- 

sors through the bowels along the line of the mesenteric attach- 
ment. In some cases it may be advantageous to tie and divide the 
upper sigmoid, after which the rectum and pelvic viscera may be 
removed together. In cases where haste is a matter of importance, the 
intestines need not be removed from the body, but at the end of the 
autopsy the region of the ileocecal valve is opened as well as the sig- 
moid and rectum, and, if no lesions are discovered here, the remaining 
portion remains unopened, unless palpation or inspection in the pre- 
liminary examination of the abdominal cavity has led one to suspect 
a lesion in other situations. If a competent dead-house assistant is 
at hand, the opening of the bowel may be entrusted to him, as it saves 
the operator's time and prevents his hands from becoming impregnated 
with the disagreeable fetid odor of the gut. The assistant is instructed 
to call attention at once to any abnormalities observed and, after wash- 
ing it, to arrange the entire bowel, mucous surface upward, upon the 
post-mortem table, so that the pathologist may at a glance examine 
the intestines throughout their entire extent. The bucket method of 
opening and cleansing the intestines — a very useful method in private 
cases — is illustrated in Fig. 82. In warm weather these viscera are 
particularly liable to undergo rapid decomposition after exposure to 
the air. If for any reason a perforation of the lower bowel is sits- 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS ny 

pected, it should be examined under water before the ligatures are 
loosened ; pressure on the intestine will cause bubbles of gas to appear. 

The small intestine is removed in a similar manner (Fig. 83) and 
opened with the enterotome along its mesenteric attachment (Fig. 84). 
If the peritoneal fluid has suggested perforation, the gut may be exam- 
ined under water. The site of perforation is usually marked by an 
area of fibrinous exudation, which may be so dense as to occlude the 
opening, or there may be several perforations, as in a case of typhoid 
fever. In duodenal ulcer the contents will be stained with bile. Ery- 
sipelas is an occasional though rare cause of intestinal ulcer. 

When the intestines are extensively agglutinated, as in appendicitis, 
tuberculous peritonitis, etc., the parts may be better studied by first 
carefully noting their relations and then removing them en masse. 

Observe whether there be distention or contraction of the bowels. 
Distention is marked in cases of stenosis or cholera and when a large 
amount of faeces is contained within the intestines. Contraction is 
noted in enteritis and after starvation. Localized constrictions may 
be due to bands of peritoneal adhesions. A Meckel's diverticulum 
should not be overlooked, and its omphalomesenteric attachment going 
to the umbilicus should be searched for. The duct sometimes remains 
patulous until puberty or even later. The greater the distention of 
the bowel the more pale is the grayish shade of the mucous surface, 
and if the contents of the gut are bloody the walls are dark red. This 
diffused color is to be distinguished from the redness due to hyperemia, 
occurring in inflammations, congestions, etc., by the marked injection 
of the capillary blood-vessels which is seen in the latter case. Even 
the vessels of the submucosa and the mucosa are observed to be over- 
filled. The lymph follicles may be injected, and are noted as irregular 
whitish lines which, when pricked, exude a drop of milky fluid, — 
chyle. The color of the normal mucous membrane is light gray, vary- 
ing according to the amount of blood present and the contents of the 
bowel. Congestion of the small capillaries causes a general redness, 
while injection of the larger vessels produces the appearance of red 
streaks ; the two conditions may occur together. Thickening of the 
walls as well as partial thickening of the mucous membrane, often in 
the form of small polyps, may be observed in many of the chronic 
inflammations of the intestines. Enlarged villi, individually made out 
with the naked eye, may be noted in some cases of inflammation. 
(Orth.) Tuberculous and typhoid ulcers are to be differentiated. 



n8 



POST-MORTEM EXAMINATIONS 



DIFFERENCES BETWEEN TUBERCULOUS AND TYPHOID ULCERS. 



Typhoid Ulcers. 

1. Direction often longitudinal, in- 

volving the Peyer's patches, which 
are larger in size; actual amount 
of surface involved greater. 

2. Edges undermined, ragged, and can 

be floated out on water ; thin, 
vascular, and composed of mu- 
cosa and submucosa ; red. 

3. Floor smooth and vascular. 



4. Peritoneal surface unaltered, except 

that it may be inflamed. No 
thickening and no gray or yellow 
patches. 

5. Mesentery unaltered; glands en- 

larged, vascular, pink, and soft- 
ened. 

6. Perforation more common both by 

separation of slough and by direct 
extension of the ulcerative pro- 
cess. Small opening by which the 
faeces may escape. Peritonitis. 
Hemorrhage may occur during 
either of these processes. 

7. Microscopically: A specific inflam- 

mation affecting the adenoid tis- 
sue; blood-vessels distended, and 
increased vascular^ of the mu- 
cosa and the submucosa. Dense 
masses of small round cells — lym- 
phoid cells and leucocytes — with 
some large multinucleated cells, 
the latter of which are derived 
directly from endothelioid cells. 
A line of demarcation is formed 
and abscess results, beginning in 
the solitary glands and other lym- 
phoid tissue of the mucosa and 
submucosa. Widal test positive. 

8. Extension takes place laterally or in 

depth. 



Tuberculous Ulcers. 

1. Direction transverse (frequently). 

This distinction is not so char- 
acteristic as is sometimes held. 
The ulcers are smaller and may 
be very numerous. 

2. Edges not undermined ; thick, promi- 

nent, nodulated, terraced, or 
sloping ; pale or red ; composed 
of tissue infiltrated with tubercu- 
lous nodules. 

3. Floor nodular, irregular, thickened, 

vascular, with pale or yellow 
points or areas. 

4. Peritoneum thickened ; small yellow 

or gray points in the floor of the 
ulcer running along the lines of 
the lymphatics. 

5. Mesentery thickened at its attach- 

ment to the bowel ; glands en- 
larged, firm and gelatinous on 
section, or caseous. 

6. Perforation, peritonitis, and hemor- 

rhage are all rare. 



Microscopically: A specific inflam- 
matory affection of the adenoid 
tissue and the mucous membrane, 
ending in caseation and connec- 
tive-tissue formation ; vascularity 
of the mucosa and submucosa ; 
increase of the connective-tissue 
cells and lymphoid cells ; tubular 
nodules, typical or caseating. it 
begins in the mucous membrane, 
and, like the typhoid lesion, is 
due to direct contagion or infec- 
tion. Widal test negative. 



Extension usually takes places later- 
ally. 



1 After Woodhead, Practical Pathology, 3d edition, p. 455. 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS no, 

9. Heals by granulation, the thin edges 9. Very rarely heals, 
falling on to and uniting with the 
granulating floor of the ulcer. 

10. Leaves a smooth, often depressed, 10. Leaves a puckered cicatrix in which 

pale, anaemic, or pigmented cica- are gray or white nodules ; often 

trix, covered by a layer of epithe- breaks out afresh. 

Hum, but no gland tissue. Sel- 
dom breaks out afresh, relapses 
being due to the affection of ade- 
noid patches previously little 
damaged. 

11. Presence of typhoid bacilli, which are 11. Presence of tubercle bacilli easily 

also found in the enlarged mesen- demonstrated. 

teric glands and in the spleen. 

12. Spleen enlarged and soft. 12. Evidence of tuberculosis elsewhere, 

especially in the lungs. 

Cases of paratyphoid fever explain the failure of the Widal test 
in a certain number of cases. A most careful study of all clinical 
typhoid cases should be made where the Widal reaction was not ob- 
tainable during life. I have elsewhere 1 suggested the possible value 
of the agglutinative test as a means of diagnosing human blood and 
its probable source. None of the lower animals suffer except experi- 
mentally from typhoid fever, and it is possible to conceive of a case 
in which blood taken from an instrument would give the Widal re- 
action and the measurements of the corpuscles be found consistent with 
the view that they were of human origin, thus showing the presence of 
human blood. The new blood test will be considered in Chapter 
XXVII. , on medicolegal suggestions. 

Whether during life a rectal enema may by reversed peristalsis be 
carried to the stomach and then vomited is an interesting but debated 
question which I believe should be answered in the affirmative. It is 
very difficult by pressure to force liquid past the ileocecal valve, but 
in relaxed conditions, as in cholera, this is perfectly possible. The 
problem is interesting as bearing on the possibility of a gastrocolic 
fistula and reversed agonal invaginations. 

An abundance of faeces in the large intestine indicates constipation, 
which occurs in an extreme form in partakers of opium, where I have 
found scybalous masses lying in pouches in the transverse colon as 
hard and dry as if they had been retained there for many weeks or 
even months. Distention of the small intestines shows that considerable 

1 Cattell, International Medical Magazine, April, 1897. 



I20 POST-MORTEM EXAMINATIONS 

food has recently been taken. When the lacteals are well dilated, some 
three and a half hours have elapsed since the taking of food which 
has reached this portion of the intestine. Pavlof finds that psychical 
secretion of the intestinal juices varies markedly according to the char- 
acter of the food ingested. When the faeces are light in color, an 
absence of bile is shown; when dark or light red, blood is probably 
present, though it must be remembered that medicines, such as haema- 
toxylin, may give a similar appearance. When dark or black, the 
presence of iron or bismuth may be suspected; if yellow, the possible 
administration of rhubarb should be considered. 

Gall-stones may be found anywhere in the intestinal tract, but most 
frequently above the ileocecal valve and lower rectum. Tapeworms 
are seen, if present. In one of my cases I found two Tcznice medio- 
canellatce, their heads being strongly attached to the mucous membrane 
beneath a fold of the valvulae conniventes at the end of the duodenum 
and not far apart. Ascarides may occur anywhere in the intestinal 
tract; a specimen in the Wistar and Horner museum of Philadelphia 
shows where one of them had penetrated the bile ducts. Seat-worms 
are found in the lower rectum. Packard removed post mortem a speci- 
men of Tcenia nana at the Pennsylvania Hospital. Of course any of 
the varieties of intestinal worms seen in man may be found here, but 
it is surprising how few cases are described in post-mortem notes of 
our hospitals. The foulest odors arise in icterus and dysentery, while 
in cholera the odor may be hardly perceptible. True intestinal sand 
may be found. 

In hemorrhage of the bowel the bleeding may be localied or dif- 
fuse. In the former variety petechial spots or ecchymoses are found on 
the mucous membrane. The mucous membrane surrounding the hemor- 
rhages may be normal, in appearance or show the results of active or 
passive congestion. In diffuse hemorrhages the blood is free in the 
bowel or may be extravasated into the mucous membrane. In the 
former case it is brownish black or black in color and usually semi- 
liquid or tarry. In the latter case the extravasated blood is in slate- 
colored or black patches. 

Appendicitis is most common in males and in early adult life, and is 
favored by fecal concretions and rarely by foreign bodies. The theory 
has recently been advanced that influenza is the cause of many cases 
of appendicitis. MetschnikofT thinks that the condition is often asso- 
ciated with worms of various sorts. The ^principal micro-organisms 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS I2 i 

are the Bacillus coli (most common). Streptococcus pyogenes, Staphy- 
lococcus pyogenes, B. tuberculosis, B. typhosus, B. influenza, Proteus 
vulgaris, B. pyocyancus, Actinomyces, etc. Mixed infection is often 
present. Of the acute forms the following are noted : Catarrhal, fol- 
licular, suppurative, and gangrenous. Of the chronic : Catarrhal, ob- 
literative, and chronic infective. In acute forms the organ is reddish 
brown, black, or greenish yellow in color. The mucous membrane is 
swollen, reddened, and presents hypertrophied follicles, ulcerations, 
or a false membrane. The whole appendix is thickened, the serous 
membrane red and lustreless. In the suppurative form the abscess may 
be small and limited to the appendix; when large the pus frequently 
invades the peritoneal cavity, the sac being formed by peritoneum, 
fibrinous exudate, and fibrous adhesions. It should be remembered 
that abscess formation may start outside of the appendix and there be no 
perforation in cases of appendicitis. In severe cases following ulcera- 
tive or obliterative conditions the abscess-cavity may contain the whole 
or a portion of the appendix which has been sloughed off. The abscess- 
cavity may become limited and remain so and be subsequently absorbed, 
or it may later open into the general peritoneal cavity. Rarely it breaks 
through the skin. It may rupture into surrounding organs or struc- 
tures, as the vagina and rectum. 

Ulceration following typhoid is often seen, and perforation is not 
unknown. In obliterative appendicitis the entire tube is thickened, firm, 
and stiff; the peritoneal surface is smooth or injected and may be 
adherent or free. It may become cystic, the contents being clear fluid 
or pus. The situation of the appendix varies greatly ; rarely it may be 
found on the left side, as in transposition of the viscera, or it may be 
entirely absent. I have seen the tip of the appendix resting beneath 
a distended gall-bladder, entering into the formation of a left femoral 
hernia, or lying in the sigmoid flexure in a case of ileocecal intussuscep- 
tion. *On microscopic examination the lymph follicles are numerous 
and close together, but as age advances they become separated and 
smaller. Late in life the appendix undergoes marked fibrous change, 
which must be distinguished from obliterative appendicitis. Primary 
cancer of the appendix has been found in several cases. 

The mesentery may be shortened by contraction, as by granulation 
of the tissue, or lengthened, as by traction upon the bowel in a stran- 
gulated hernia. Hemorrhage takes place into this tissue in phosphorus 
poisoning and in acute yellow atrophy of the liver. The glands are red 



122 POST-MORTEM EXAMINATIONS 

and swollen in enteritis, especially in typhoid fever, where they may 
be very numerous and break down. They afford a most favorable spot 
from which to secure cultures for the different varieties of colon and 
typhoid bacilli. When the glands become tuberculous, they often 
caseate and may reach a large size. In tabes mesenterica in children 
they are usually enlarged even in non-tuberculous cases. All statistics 
bearing upon tuberculous infection of these glands is extremely useful 
at the present time, in order to place upon a sound scientific basis the 
relation of tuberculous milk to infant mortality. We also find enlarged 
glands in leukaemia and Hodgkin's disease. By the stopping up of the 
vessels, the mesentery may become gangrenous. It may be wholly con- 
verted into a mass of fat. Search should be made for calcified tuber- 
cles, tumors, chylocysts, etc. Thrombosis and embolism of the mesen- 
teric vessels should also be thought of. Hemorrhagic infarcts are 
sometimes seen. Parasites of various kinds have been described and 
aneurisms have been noted. 

More people die from dysentery than from plague, cholera, and 
yellow fever. Found especially in warm climates and after eating im- 
proper food. I. Acute. — (a) Catarrhal, (b) Amoebic, (c) Gan- 
grenous. II. Chronic. In the early stages the bacillus of Chante- 
masse 1 is found, and in the later stages, especially where abscess 
develops, the amoeba coli is seen. The blood of patients affected with 
tropical dysentery has an agglutinative reaction with the bacillus of 
dysentery. Summer diarrhoea of children has also recently been shown 
to be due to the same organism. All the lesions of dysentery have cer- 
tain points of election for the starting of the inflammatory process, — 
viz., the large bowel, the flexures of the large bowel, and the course of 
the valvulse conniventes. (i) Acute Catarrhal Dysentery. — The mu- 
cous membrane is enlarged, swollen, and covered with tenacious blood- 
stained mucus. The solitary follicles stand out prominently and in 
protracted cases often show necrotic or suppurative change. In some 
cases numerous ulcers appear throughout the large bowel. In children 
the picture is that of an acute follicular colitis. At first glance the 
mucous membrane seems to be universally congested ; on closer exami- 
nation it is found to be more or less streaky, with bright-red pin-point 
areas of intense congestion. The peritoneal surface is enlarged, lustre- 



1 Commonly spoken of as the bacillus of Shiga, though described by Chaxte- 
masse and Widal in 1888. Presse med., July 23, 1902. 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS i 2 $ 

less, and sticky. (2) Amoebic Dysentery. — In this form the amoebae, 
•of which there are several kinds, both pathogenic and non-pathogenic, 
are almost always present. These are unicellular protoplasmic motile 
organisms, five or six times the size of a white blood-corpuscle. They 
contain a nucleus and one or more vacuoles. The characteristic lesion 
is an ulcer, which has a small external opening, with extensive under- 
mined infiltrated edges. Sometimes these ulcers run together, forming 
deep sinuous tracts bridged over by apparently healthy mucous mem- 
brane. There is a progressive infiltration of the connective-tissue 
layers of the intestine, causing pressure upon the blood-vessels and sub- 
sequent necrotic changes in the overlying structures, so that the mucosa 
or the muscularis may be sloughed off en masse in certain parts of the 
bowel. In severe cases the whole of the intestine may be much thick- 
ened and riddled with ulcers, with only here and there islands of intact 
mucous membrane. More rarely these ulcers have but slightly under- 
mined edges, the borders being more or less cleanly cut. In some cases 
there is a tendency to purulent formations. (3) Gangrenous Dysen- 
tery. — This form is characterized by the formation of a diphtheritic 
membrane, which is more or less irregularly distributed; it is at first 
yellowish brown, in later stages becoming black or ashen-gray ; in the 
latter case it appears as sloughs more or less easily detachable. There is 
thickening of all the coats of the intestine, with great interference with 
the blood-supply, so that in severe cases whole portions of the bowel 
may become gangrenous. (4) Chronic Dysentery. — In this form the 
anatomical changes are variable. Deeply pigmented ulcers are often 
present or there may be cicatrizations; again, no trace of ulceration 
may appear, but the entire mucous membrane presents a rough, irregu- 
lar, figured appearance, in places slate-gray or blackish in color. Cer- 
tain parts of the mucosa are greatly thickened and the muscular coat is 
hypertrophied. In some cases the solitary follicles are enlarged and 
pigmented. At times the outlets of tubules of the glands are closed, 
thus forming " slime cysts" (Orth), varying in size from a pin-head to 
a. pea. The condition is called chronic cystic enteritis. The calibre 
of the bowel may be reduced, but stricture is very rare. Complica- 
tions. — (a) In all cases dysentery may be complicated by peritonitis, 
pleurisy, pericarditis, or pysemic manifestations, (b) In amoebic dysen- 
tery the characteristic complication is the abscess of the liver, which is 
usually single and occupies the right lobe. It may be multiple, when 
it is apt to be distributed superficially in any or all of the lobes. It 



124 



POST-MORTEM EXAMINATIONS 



is a large solitary abscess, the wall of which is made up of broken- 
down, rough, shaggy liver-tissue, without any of the ordinary pyogenic 
membrane. The contents of this abscess vary. The outer portions are 
gelatinous and composed of broken-down liver-tissue, blood-pigments, 
pus-cells, amoebae coli, etc. The interior is usually of an almost watery 
consistency, and of a brownish or reddish color. In some cases cultures 
made from these abscesses are sterile. In hot climates the amoebae coli 
can almost always be found on microscopical examination. 

In colitis, or inflammation of the large bowel, consider: (a) Early 
life, (b) Summer weather. (<:) Improper foods, (d) Certain micro- 
organisms, (e) Poisons. (/) Some infectious diseases. Classifica- 
tion. — (a) Simple, (b) Membranous, (c) Ulcerative, (d) Chronic. 
( i ) In simple colitis the mucous membrane is much thickened and red- 
dened, the rugae are prominent, and petechial hemorrhages are com- 
mon. In ordinary inflammation the follicles are inflamed and oedema- 
tous and on section they appear like pearls. When there is a marked 
cell increase, they are white or gray and more prominent. These fol- 
licles may become confluent. (2) Membranous colitis is characterized 
by the formation of a more or less complete cast of the intestine, usu- 
ally from one inch to six inches in length, but it may extend a distance 
of several feet. The membrane usually appears homogeneous, but may 
be distinctly laminated and show deposits of fecal matter between the 
layers. The end of the cast may be well defined, but often shades off 
into a transparent gelatinous material. Associated are swelling and 
oedema of the submucosa. The mucous membrane not involved is very 
much inflamed and there may be hemorrhagic infiltration. The intes- 
tine may show that perforation has occurred and gangrene may some- 
times supervene. (3) In ulcerative colitis the appearances vary greatly : 
the ulcers may be small and numerous or they may be large in size and 
few in number. They may -be perfectly regular in outline, but are 
usually irregular, with slightly undermined edges. The floor of the 
ulcer generally shows a somewhat sloughing bowel. The ulcers may 
communicate by separation of layers of the intestines. In long-standing 
cases they are often intensely congested and tend to become transverse. 
Sometimes the floor of the ulcer becomes so thin as to be pushed out 
and form pouches. In very acute cases the mucous membrane is much 
reddened, highly vascular, and the surface is soft. The peritoneal coat 
of the bowel may be normal in appearance, but is usually red, some- 
what sticky, and shows many dilated blood-vessels. Small hemor- 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS 



125 



rhages are common. (4) In chronic colitis the bowel is often much 
thickened in all its coats. It may be larger in diameter. It is firm, 
even leathery, to the touch. The mucous membrane is hypertrophied, 
often much pigmented, and shows many small hemorrhages. The fol- 
licles are swollen and have a slaty appearance. There may or may not 
be ulceration. 

There are four forms of dilatation of the colon: (a) Distention 
from gas. (b) Distention due to some solid substance within the 
bowel. (c) Distention caused by an organic obstruction in front of the 
dilated bowel, (d) The so-called idiopathic dilatation. 

Malignant disease of the colon is generally a cylindrical-celled epi- 
thelioma, usually confined to a small area, where its contraction sets 
up an annular stricture. 

THE KIDNEYS AND ADRENALS. 

The spleen and intestines having been removed and the liver turned 
over into the thoracic cavity, as described on page 95, the kidneys and 
suprarenal bodies yet remain behind the peritoneum, deeply embedded 
in the perinephrial fat. Of course, in anomalous cases, in certain dis- 
eases and deformities (notably Pott's disease), and in floating kidney 
they may be considerably displaced. In any event it is best and simplest 
first to find the ureters as they descend on the psoas muscles and enter 
the pelvis. The exact situation of the ureters is as follows : Each 
ureter at first passes obliquely downward and inward to enter the cavity 
of the true pelvis and then curves forward and inward to reach the 
base of the bladder. In its whole course it lies close behind the perito- 
neum and is connected to neighboring parts by loose areolar tissue. 
Superiorly it rests upon the psoas muscle and is crossed very obliquely 
from within outward by the spermatic vessels, which descend in front 
of it. The right ureter is close to the inferior vena cava. Lower down 
the ureter passes either over the common or the external iliac vessels, 
behind the termination of the ileum on the right side and the sigmoid 
flexure of the colon on the left. Descending into the pelvis it enters 
the fold of the peritoneum forming the corresponding posterior false 
ligament of the bladder, and, reaching the side of the bladder near its 
base, runs downward and forward in contact with it, below the oblit- 
erated hypogastric artery, and in the male is crossed upon its inner side 
by the vas deferens, which passes down between the ureter and the 
bladder. In the female the ureters run along- the sides of the cervix 



126 POST-MORTEM EXAMINATIONS 

uteri and the upper part of the vagina before reaching the bladder. 
(Quain's Anatomy.) 

Incise the peritoneum on the left side first, then on the right over 
and in the direction of the brim of the pelvis, and follow up each ureter, 
gently tearing away the loose connective tissue, but being careful not 
to disturb seriously the relationship of the kidney and adrenal and their 
vessels until they have been noted. If this method be adopted, there is 
no need of making an incision in the peritoneum directly over the 
kidney, as is recommended by most pathologists. The organs may 
next be " shelled out" of their bed of cellular tissue and fat and the 
vessels severed, thus permitting their removal from the body. The 
adrenal 1 is then separated from the kidney, weighed, measured, and 
incised in its greatest plane. Should disease of the bladder or ureters 
be present, the kidneys may be removed from the body with the ureters 
attached. This is always better in those very common cases where 
double ureters are found. One nick is then put in the left kidney at 
its upper or lower border, and the kidney and adrenal are removed, or 
the kidney may first be dissected. Another method of distinguishing 
the right kidney from its fellow is to make a uniform rule as to which 
ureter shall be left the longer by several inches on the separation of 
the kidneys from the body. The kidney is then cleaned and weighed, 
and any peculiarities are noted. 

To remove the kidney while the intestines are still in the body, 
first hold aside the left sigmoid flexure and pull away the fundus of 
the stomach and the tail of the pancreas. Then make a long incision 
in the convex border of the kidney. Next separate it from the sur- 
rounding tissue and cut it out along with the suprarenal. The right 
kidney lies under the liver, and in removing this suprarenal be careful 
not to cut the inferior vena cava. If you remove the ureters with it 
(Fig. 85), on the right side a long incision must be made through the 
peritoneum that goes from the abdominal wall to' the caecum and colon. 
(Orth.) Nauwerck recommends a more complicated method. He cuts 
the descending colon from the mesocolon first. His primary incision 
is vertical and between the hilum and the spinal column, a second one 
being made in the convex border of the kidney. 

Holding the kidney longitudinally in the hand, the hilum towards 

1 The right adrenal is more difficult to find than the left, and may be permitted 
to remain in the body until after the removal of the stomach, duodenum, and pan- 
creas, but should be sought for before the removal of the liver. 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS i 2 y 

the palm and the convexity upward, a clean brain-knife or large carti- 
lage-knife is used to divide it through its middle parallel to its greatest 




Fig. 86. — Method of opening the kidney. The organ is held in the left hand with its hilum down- 
ward, and an incision is made with a brain-knife along its upper convex border and more than half 
through the renal substance. It is then reversed (Fig. 87), and the incision continued until the gland 
is nearly, but not quite, divided. In this manner there is no danger of cutting the hand. 




Fig. 87. — Method of opening kidney in such a manner as not to injure the hands of the operator. 

surface. The knife must be so sharp that it will cut without tearing, 
and care should be taken not to extend the incision through to the hand 



I2 8 POST-MORTEM EXAMINATIONS 

(Fig. 86). The wisest precaution for this purpose is first to bisect the 
kidney only to its centre, then reverse the organ in the hand and com- 
plete the incision by cutting outward (Fig. 87). The pyramids will 
now be completely exposed and the two halves held together by the 
tissues composing the pelvis. If it be desired to lay open the hilum, 
this should be done with scissors. Precipitates of urinary salts in the 
pelvis are often mistaken for pus. A microscopical examination, espe- 
cially if acetic acid be added, will at once reveal the true nature of the 
fluid. Now examine the surface for cysts, stellate veins, aberrant 
adrenals, miliary tubercles, tumors, etc. Large cysts can readily be 
seen. When incising a cystic kidney it should be remembered that the 
liquid therein is often under considerable pressure, and may squirt 
several feet when the cavity is opened, and thus injure the eyes or soil 
the clothing of the operator or of those present at the autopsy. 

The capsule, which when normal is transparent, is next stripped off 
from one side, and its condition noted as to whether or not it is thick- 
ened, adherent or non-adherent. If adherent, see if any of the cortical 
substance is removed with it, — i.e., whether the inner surface is smooth 
or rough. The normal color of the surface of the kidney after removal 
of the capsule is brownish red. 

The relation existing between the lighter cortex and the darker 
medulla is determined by drawing a straight line from the apex of one 
of the largest central cones of a pyramid to the surface of the kidney. 
Normally this relation is as one (cortex) to three (medulla) ; it is, 
however, frequently altered and should always be noted. The cortical 
substance is increased in parenchymatous nephritis and decreased in 
chronic interstitial nephritis. Also study the color of the external and 
cut surfaces, the quantity of blood or fluid exuding and its character, 
and the consistence of the organ. Thus, in parenchymatous nephritis 
the color of the cortex is a grayish white or light yellow, in poisoning 
by hydrocyanic acid much blood exudes, and in chronic interstitial 
nephritis the nephritic tissue is dense and hard. Both anaemic and 
hemorrhagic infarcts occur. Scars are often found, and may be due 
to many different causes, as gummata, thromboses, infarcts, stones, 
former operations, etc. Tumors of the kidney, especially fibroid, are 
quite common. With atheromatous and granular kidneys, suspect apo- 
plexy, especially if there has been a clinical history of flushing of the 
face. As a routine practice in the examination of the kidney, the amy- 
loid reaction should be tried. A thin slice about one inch square, 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS 



129 



including both cortex and medulla, is removed from the organ and 
placed in Lugol's solution (which is preferably diluted four or five 
times) for several minutes and then examined with a hand glass in a 
good light. 

Where decapsulation as an operative therapeutic measure has been 
practised, also after the scraping of the hepatic peritoneum for ascites, 
the post-mortem examination should be very thorough, as any informa- 
tion concerning such cases is most important at the present time. 

The adrenals are best removed attached to the kidneys, though, as 
already stated, the ablation of the right adrenal with the kidney is more 
difficult than that of its fellow, and for this reason it is often left in the 
body and examined at the time of the removal of the pancreas. The 
adrenals are very delicate and care must be exercised lest they be in- 
jured in their excision. Normally the adrenals consist of three layers, 
which differ more or less in the young and the old. The outer or cor- 
tical layer is light yellow in adults and grayish red in children. This 
tissue somewhat resembles that found in the thyroid gland. It is com- 
posed of radiating follicles whose cells are undergoing fatty degenera- 
tion. It will be seen in the new-born that the adrenals are relatively 
of large size in comparison with the* kidneys and when examined 
microscopically no fatty metamorphosis is discovered. The inner or 
medullary substance is composed of neuroglia and ganglionic cells 
connected with a rich vascular supply. The middle zone, or inter- 
mediary substance, is brown, owing to pigmentation of the follicles. 
The amount of intermediary substance is subject to considerable varia- 
tion (Langerhans). Later on in life there is a tendency for the central 
part to become separated from the intermediary portion, and in atrophy 
of this organ when it takes place unevenly (as it frequently does) 
nodes are left on the surface which are not unfrequently mistaken for 
tubercles. These organs are subject to numerous pathological changes 
and are hyperplastic in many varieties of congenital deformities in 
which other nerve tissue is affected. We may have here hematoma, 
melanoma, cysts, hypertrophy, glioma, primary cancer, echinococcic 
cysts, hsematoid degeneration, tuberculosis, purulent infiltration, and 
internal proliferations. The recent discovery of the marked action of 
adrenalin would seem to show the presence of an internal secretion 
acting directly upon the vascular apparatus. It by no means follows 
that the adrenals will be found affected either macroscopically or micro- 
scopically in all cases of Addison's disease. Exquisite miliary tubercles 

9 



!3o POST-MORTEM EXAMINATIONS 

are seen in the adrenals, and the caseating mass in advanced tubercu- 
losis may reach the size of a walnut. 

Addison's disease is most frequently seen in laborers between the 
ages of twenty and forty years. It may be due to: (a) Tuberculosis, 
simple atrophy, cirrhosis, hemorrhage, or tumors of the adrenals, (b) 
Inflammation or pressure of structures bordering the adrenals, (c) 
Changes in the semilunar ganglia and the sympathetic system. The 
adrenals are most frequently tuberculous, and there is always a de- 
ficiency of the internal secretion of these organs. The brownish pig- 
mentation (bronze disease) is most marked on the chest. The spleen 
may be enlarged, as may also the thymus, if the latter organ persists. 
The stomach and intestines may show hypertrophied lymphoid follicles. 
No specific blood-changes have been observed. One of the most marked 
cases of pigmentation of the abdomen which I ever saw was that of a 
girl who had undergone an operation for the removal of a large der- 
moid cyst of the ovary. It is possible that in this case the semilunar 
ganglia or the adrenals were affected by pressure or otherwise. In two 
cases of primary sarcoma of the adrenal, and in one of general tuber- 
culosis with marked involvement by caseous tubercles of both adrenals, 
I observed no pigmentation of the skin at the time of the autopsy. 

SEMILUNAR GANGLIA. 

The semilunar ganglion or cceliac plexus, which receives the 
great splanchnic nerve and the pneumogastric, is situated behind the 
stomach and in front of the crura of the diaphragm, by the side of the 
cceliac axis and the root of the superior mesenteric artery, and close to 
the suprarenal body (Fig. 88). The ganglia should be carefully 
studied microscopically in all cases where lesions are suspected in the 
adrenals or in the sympathetic system. The color and vascularity as 
well as the condition of the surrounding connective tissue should be 
noted. In cholera and typhus fever the ganglia are hyperaemic and 
may show evidence of the occurrence of hemorrhage ( Rokitansky ) . 

THE URETERS. 

The ureters may be distended with urine, as from an impacted 
stone, from cancer of the uterus, and from overfilling of the bladder. 
They are often double, most frequently uniting in their middle third, 
more rarely in the structure of the bladder, but may enter this viscus 
by separate papillae. The ureters being slit open throughout their entire 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS ^ 

extent, the appearance of the mucosa is described, taking into account 
the color and character of any catarrhal exudate, should it be present. 
Many microscopists teach methods of diagnosing the situation of a 
lesion in the urinary tract from the shape of the epithelial cells. A 
most interesting experiment is to take at a postmortem scrapings from 
the pelvis of the kidney, the ureter, bladder, and urethra, examine them 




Fig. 



-The relations of the pancreas, kidney, ureter, adrenal, and solar plexus are shown, the liver 
having been turned upward and the intestines shoved over to the right. 



under the microscope, and determine whether or hot such a diagnosis is 
possible. Hemorrhages, abscesses, papillary fibromata, the Distoma 
hcematobium, calcified bodies, etc., are found in the ureter. Miliary 
tubercles of the mucous membrane are seen, often of typical shape and 



large size. 



In some three hundred autopsies performed in one year, I met with 
three cases in which the ureter had been tied during abdominal opera- 
tions on the uterus and its adnexa. The right ureter seems to be liga- 
tured oftener than the left. 



™ POST-MORTEM EXAMINATIONS 

If it be desired to collect the urine for microscopical, chemical, or 
medicolegal examination, it should be drawn off into a sterilized vessel 
with a new catheter. Should strychnine poisoning be suspected, place 
a live frog in the urine, and if strychnine is present in any amount the 
frog will show the typical strychnine convulsions. Unfortunately, 
however, in strychnine poisoning the alkaloid is not always secreted in 
the urine, the quantity of which is often very small. 

PELVIC ORGANS. 
Removal of the Female Genitalia. — By means of a circular 
incision, starting and ending at the symphysis pubis and including the 
anterior portion of the sacrum, the parietal peritoneum is freed around 
the entire brim of the true pelvis. Orth begins the incision between 
the rectum and the sacrum, while Schottelius recommends the ending 
of the incision at the posterior superior spine of the ilium. The body is 
then placed in the position seen in Fig. 89, and the thighs are separated. 
An oval incision is next made, starting above the external genitalia, 
below the symphysis pubis, and ending behind the anus near the coccyx 
(which may be examined at this time), passing to the outside of the 
labia on each side. Traction is then made upon the soft parts towards 
the median line and the incision deepened, keeping as close as possible 
to the pelvic bones and taking care that the knife or scissors cutting in 
the direction of the long axis of the body does not injure the rectum, 
bladder, or external genitalia. It is now possible to remove the external 
genitals, bladder, and rectum through the abdominal cavity, or the in- 
ternal parts through the oval incision exteriorly. (Figs. 90 to 97 inclu- 
sive.) Whichever method is adopted, the muscles, fatty tissue, and 
fascia holding the parts in place are to be severed without injury to the 
tissues desired to be preserved. Or an internal or external hysterectomy 
may be performed, if for any reason the external incisions should be 
avoided. If the ureters and kidneys have been left connected, they may 
be removed at the same time. After the pelvic organs have been excised 
they are placed on a board upon the table in the same relative posi- 
tion that they occupied while they were in the body. The bladder is 
then opened anteriorly with the scissors on the median line from the 
fundus to the urethra, not neglecting to open this (and in the male to 
observe the prostate). 1 The rectum is slit up along its posterior wall, 

1 Many obducents partially open the bladder while it is still attached to the 
body; indeed the entire examination of the pelvic organs can be made with the 
parts in situ. 




Fig. 89.— Position in which the body is advantageously placed for examination of the rectovaginal region 
and for the performance of a postmortem per vaginam or per rectum. The body is drawn down towards the 
end of the table and the hips are elevated with a block. The thighs are then strongly flexed and held securely 
in place by a bandage fastened beneath the table. 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS 133 




Fig. 



-Method of opening the uterus ; the lines show the places for the incisions, one of 
which has already been started at the cervix. 




Fig. 99. — The uterus has been incised in the manner called for in Fig. 98. The ovary and the tube 
are opened. The fimbriated extremity, the hydatid of Morgagni, and a corpus luteum are well shown'in 
the illustration. 



! 34 POST-MORTEM EXAMINATIONS 

while an anterior incision is chosen to examine the uterus. When it is 
desirable to preserve the exterior of the bladder intact, the rectum may 
be dissected away and the womb incised posteriorly, or the bladder may 
be removed so as to permit of the. uterus being opened up anteriorly. 
A transverse incision in the uterus from the entrance of one oviduct to 
that of the other will give an opportunity for a study of their uterine 
termini, which are sometimes rather difficult to find. Each ovary is 
completely bisected through its free surface, with the exception of 
enough tissue at the bottom to hold the two halves together. (Figs. 
98 and 99.) For the method of closing the external opening, see 
directions under Figs. 94 to 97 inclusive. 

Removal of the Male Organs of Generation. — In the male 
the bladder is pressed downward well towards the' rectum, and the 
tissues thus put on a stretch are incised close to the under portion of the 
symphysis pubis. A circular incision is then made anterior to the 
rectum and as close as possible to the parts to be removed (seminal 
vescicles, prostate, Cowper's gland, bulbus, etc.) without injuring them 
or buttonholing the skin. The soft tissues of the penis (cavernous and 
membranous portions of the urethra) are dissected away from the skin 
from within the pelvis, traction being made to draw these parts into 
the pelvic cavity as fast as those above are loosened. The corpora 
cavernosa" and corpus spongiosum being now fully exposed, they are 
incised transversely near the attachment of the prepuce, just below the 
corona glandis and frsenum. By pulling on the spermatic cords from 
above and pushing up the testicles from below, these organs are then 
removed together. The skin of the penis and scrotum is well stuffed 
with cotton, so as to conform as nearly as possible to the original shape 
of the parts, or, if desired, after dissection of the testes and their appen- 
dages, they may be returned to their normal situations. Unless by an 
accidental perforation of the skin, — as the knife is working in the 
dark, — there need be no visible deformity if this method be properly 
carried out. The rectum and the bladder and its component parts may 
be left attached or can be separated, as preferred. 

The technic of my external method of examining the testicles, 
urethra, spermatic cord, etc., without mutilating or disfiguring the 
external genitals, is as follows : The penis is grasped with the left hand 
and drawn upward and backward over the symphysis pubis in such a 
manner as to expose its under surface and the scrotum. With the 
thumb and forefinger of the same hand a fold of skin is taken up at 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS ^5 

the point where the integument of the penis merges into that of the 
scrotum. This fold, which should be in the line of the long axis of 
the penis, having been drawn taut, incision is made across it at right 
angles to the line of the penis. If this transverse incision be not 
carried too far, it will leave an oval gap about an inch and a half in 
diameter when the fold of skin is allowed to fall back. This will be 
quite large enough to permit the proper execution of the subsequent 
steps of the operation, though the wound after being sewed is so 
small that it is entirely concealed by the penis when replaced in its 
normal pendent position. The finger is next introduced into the 
scrotum and swept around so as to break up the delicate areolar con- 
nective tissue that forms the septum scroti and unites the dartos with 
the testes; then by slightly dilating the external wound the testicles 
can be removed from the scrotal sac. Next the root of the penis is 
grasped from within, and the extremely loose bands of connective 
tissue that unite the body of the organ to the integument are broken 
up, still using only the finger. These connections having been severed, 
the body of the penis can be drawn from its cutaneous sheath as far as 
the point of union of the prepuce with the tissues at the cervix, so 
that now the testes and the penis as far as the glans are exposed 
denuded of their cutaneous investment. In severing the body of the 
penis from the glans and the tissue included in the inverted sheath of 
skin, great care must be exercised not to " bottonhole" the delicate 
structure of the prepuce. This accident can be avoided by amputating 
the glans at a point one- fourth of an inch from the corona (which 
can be plainly seen and felt through the delicate skin covering it), 
and carrying the incision parallel to its plane. The direction of the 
incision will be downward and forward, for in the position in which the 
integument attached to the cervix now holds the penis the frsenum is 
in front. The amputation of the glans is most conveniently performed 
with scissors, the body of the penis being supported by the thumb and 
first finger of the left hand. (Figs. 100, 101, and 102.) 

Nauwerck describes the following method of finding the seminal 
vesicles : They lie as long flattened organs on the lateral side of the 
spermatic duct immediately above the prostate and the posterior wall 
of the bladder. The fundus of the rectovesical excavation is held up, 
and the index-finger is placed in the incision in the prostate, the middle 
finger in the posterior wall of the bladder, and the thumb on the 
rectum, which on being pulled downward exposes the back part of the 



136 POST-MORTEM EXAMINATIONS 

neck of the bladder, upon which rest the seminal vesicles. Or, cut 
through the peritoneum in the depth of the excavatio rectovesicalis 
and dissect up the spermatic cord until the vesicles are reached. They 
are then to be incised and the duct opened up with a fine pair of 
scissors. (Fig. 103.) 

THE LIVER AND GALL-BLADDER. 

The liver is removed from the body by severing its attachments to 
the diaphragm, falciform ligament, blood-vessels, and ducts, and break- 
ing up any existing adhesions. For this purpose traction is made by 
introducing the left hand behind the right lobe and raising the liver so 
that it hangs over the ribs of the right side (Fig. 104). Nauwerck 
removes the organ by finding the hepatoduodenal ligament and then, 
introducing the index-finger into the foramen of Winslow, pulling it 
somewhat towards the duodenum and cutting from right to left over 
the finger the ductus choledochus to the right, the hepatic artery on the 
left, and lastly the portal vein which lies between the two posteriorly 
(Fig. 105 ) . The liver is then weighed and measured, and the color and 
condition of the surface are noted. After examination of the serous 
surface of the gall-bladder and duct, the sac should be laid open by a 
longitudinal incision carried through the duct. 

The liver is laid on its posterior surface and a series of parallel 
incisions about half an inch apart, which do not completely pass through 
the organ, are made, either longitudinally or, still better, transversely 
(Fig. 106). 

In pernicious anaemia the presence of free iron may be shown by 
placing a thin strip of hepatic tissue in a ten per cent, solution of potas- 
sium ferrocyanide for several minutes and then washing it thoroughly 
with a two per cent, solution of hydrochloric acid. The production of a 
blue color (Prussian blue) indicates the presence of iron. 

Observe: Bile ducts: (a) caliber, — normally that of a thin goose- 
quill, may be closed, or may be of the size of a finger ; (b) gall-stones ; 
(c) ulcers. Portal vein : (a) color of blood; (b) thrombosis; (c) 
caliber, — may be thin as result of old inflammation; (d) periphlebitis. 
Gall-bladder: (a) size; (b) adhesions; (c) tumors; (d) contents, 
— 1, bile (note its color, — light or dark yellow, reddish yellow, greenish 
yellow, — quantity, quality, etc.); 2, foreign bodies, — gall-stones; 3, 
mucous membrane, — thickening, change in color, and inflammations. 
Liver: (a) position; (b) size, — increased in parenchymatous inflam- 




Fig. ioo. — Method of examining testicles, epididymis, spermatic cord, etc., without disfigurement. 
The primary incision is made in the median raphe in such a manner as to be covered when the penis is 
returned to its normal situation. 




Fig. ioi. — Testicles shelled out of the scrotum through the opening made in Fig. ioo. 




Fig. 102. — Appearance of the male external genitalia preparatory to minute examination in the author's 
method of exposing them without disfigurement. 




Fig. 103.— Method of opening the seminal vesicles. The lines above the seminal ducts show the 
places of incision used to examine the seminal vesicles, a, a, edge of severed portion of peritoneum ; 
b, urinary bladder ; c, c, seminal vesicles ; d, d, spermatic ducts. 




Fig. 104.— Removal of the liver from the body. It is held in the left hand and incision is made 
towards the operator. This stretches the diaphragmatic attachments of the large blood-vessels, so that 
they may readily be incised. 



Hepatic artery 
Portal vein 

Ductus chole- 
dochus 



Gall-bladder 



Liver 



Pylorus Stomach 



Duodenum 



Inferior vena 
cava 

Spermatic vein 
Ureter 




. Portion of 
O diaphragm 



Pancreas 



-Spermatic vein 



Ureter 



Fig. 105. — Examining the bile ducts. The left index-finger is introduced into the foramen of Winslow, 
and supports the hepatic artery, the portal vein, and the ductus choledochus, into the latter of which a 
sound has been introduced and-is seen coming out of the opening in the duodenum. (After Nauwerck.) 




Fig. 108. — Method of examining the stomach, which in this case was markedh- hypertrophied. Rubber 
gloves are very useful for this purpose. 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS 



137 



mation, decreased in atrophy; (c) form, — fissures or granular distor- 
tion of surface; (d) color, — brown or brownish red normally, yellow 
in fatty infiltration, dark brown in atrophy, gray in amyloid and inter- 
stitial overgrowth, ochre-yellow in acute yellow atrophy, green in icte- 
rus, or dirty green when decomposition sets in; (e) consistence, — 
normally rather hard (pitting soon disappears), increased in amyloid 
disease, the pitting remaining for some time, softer in parenchymatous 
affections and early stages of acute yellow atrophy, fluctuates in echino- 
coccus cysts and abscesses; (f) capsules, — normally transparent, but 




Fig. 106. — Method of incising- the liver. Long parallel incisions are made from the right lobe to the 
left, care being taken not to cut through the organ, which would prevent reconstructing it in its normal 
state, nor to extend the incisions so deeply as to injure the gall-bladder. The structures of the under 
surface of the liver have been previously dissected. 



thickened in chronic inflammation, syphilis, etc.; (g) section, — 
smooth, uneven, rough, or granular; (h) lobules, — notice that they 
are separated by connective tissue, more distinct in cirrhosis, less so in 
acute yellow atrophy. It is well to remember that in man the separation 
of the lobules by the connective tissue of Glisson's capsule is not at all 
well marked. Observe whether the lobules are larger or smaller than 
normal. Notice that the color is darker in the centre of the lobule 
than at its periphery (cyanotic induration). See if the periphery is 
yellow (fatty infiltration). On section note whether the tissues retract 



i3« 



POST-MORTEM EXAMINATIONS 



as in high-grade cyanotic atrophy, or project as in fatty liver, 
degeneration affects especially the middle zone. 



Amyloid 



DUODENUM, OUTLET OF THE COMMON BILE DUCT, STOMACH, 

AND CESOPHAGUS. 

The duodenum may be slit while still in situ, or it can be excised 
together with the stomach, liver, and pancreas, and the whole dissected 
after removal from the body. The gut is best opened with a knife, 
starting at the tied end about the centre of its anterior surface and with 




Fig. 107.— Relations of the gall ducts and duodenum. The gall-bladder in this case was packed with 
stones, and one large one was found in the common bile duct. In this case the pancreatic duct communi- 
cated with the duodenum by a separate outlet, and a probe is seen emerging from the opening through 
which the bile normally finds its way into the duodenum. 

the enterotome cutting more and more to the right until at the pylorus 
the incision almost reaches the posterior surface of the duodenum. 
(Fig. 107.) The papilla, the outlet of the ductus choledochus com- 
munis, can usually be discovered if it be remembered that it appears 
as an elevation of the mucosa near the junction of the second (descend- 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS 



139 



ing) portion and the third (transverse or oblique) portion of the 
duodenum, about three and one-half inches from the pylorus, just 
below the head of the pancreas, and towards the inner and back part 
of the duodenum. The duct runs for three-quarters of an inch in 
the muscular coat of the bowel, where it is usually joined by the 
pancreatic duct. A small magnifying-glass will often enable one to 
distinguish the papilla from the valvulse conniventes. Pressure upon 
the gall-bladder, as suggested by Virchow, will cause bile to flow 
out (but care must be taken not to dislodge a gall-stone, either here or 
in the cystic duct) and thus reveal the opening of the duct. Another 
way is to follow down the cystic duct, make a transverse incision in it, 
introduce downward a small probe or piece of broom until this emerges 
through the opening in the papilla, and then slit it with a knife or scis- 
sors. Orth says that if after finding the head of the pancreas the intes- 
tines are stretched transversely the outlet will readily be discovered a 
little below the middle of the head. 

Unless poisoning is suspected (see pages 325 and 342) the stomach 
is incised along the greater curvature, a little beloiv the cardiac orifice 
and a little above the pyloric, the contents are removed and the openings 
examined, when the incision is extended in both directions until the 
entire viscus is laid open. The mucous membrane may be washed by 
allowing a gentle stream of water, as from a sponge, to flow over it, 
but it should never be rubbed with the sponge. The organ may be 
opened and examined without removal from the body (Fig. 108). 
Should it be desired to find the artery from which a hemorrhage has 
occurred in a gastric ulcer, water is injected into the gastric artery 
supplying this area, and it will be seen to exude from the open part. 

The contents of the stomach should be examined as to their quan- 
tity, consistency, reaction, odor, gas formation, foreign bodies, color, 
inflammation, and infectious granulomata. Blood coming from the 
lungs is apt to be mixed with air, frothy in character, and redder than 
blood issuing from the oesophagus or the stomach itself, where, if the 
vessel be of good size, large, compact, blackish-red lumps appear. The 
blood from cancer is blackish brown (the so-called coffee-grounds ap- 
pearance) ; that from diapedesis, cirrhosis of the liver, and inflamma- 
tions is a brownish homogeneous mixture combined with mucus. The 
biliary pigments often impart to it a yellowish or greenish hue. In 
peritonitis and in obstruction to the bowel the gastric contents may be 
fecal in character. 



I4 POST-MORTEM EXAMINATIONS 

The oesophagus is opened up along its anterior surface throughout 
its entire median extent either while in situ or after its removal from 
the body (Fig. j6). Its caliber may be directly determined by grad- 
uated cones, or may be calculated by dividing by 3.14 its linear meas- 
urements made after it has been laid open. 

In cancer consider heredity, sex (more common in the male), age 
(average about fifty years), previous history of a gastric ulcer, and 
place of origin, inquiring particularly whether or not other cases have 
occurred in the same house. Cylindrical-celled cancers are found espe- 
cially at the pylorus, while squamous epitheliomata occur mostly at 
the cardiac end of the stomach. The tumor may be hard (scirrhous), 
soft (medullary), or colloid, (a) Scirrhus. — The growth starts as a 
small nodule, usually at the pylorus, often sharply defined, and very 
hard. It is whitish on section and no cancer-juice exudes from the cut 
surface. Stricture of the pylorus with hypertrophy and dilatation of 
the stomach is common. Connective tissue is very abundant and can- 
cer-cells are few. Ulceration occurs late in the disease, (b) Medul- 
lary. — This tumor tends to become larger than the previous one. It 
contains much less connective tissue and is therefore softer. It involves 
all the coats and is not circumscribed. It ulcerates very early and hem- 
orrhages are frequent. As in the previous instance, metastasis is very 
common, (c) Colloid. — This variety usually consists of gelatinous 
cancer-cells in a condition of colloid degeneration. It extends over the 
entire stomach and metastasis is very rapid. Metastasis in all the forms 
affects the various tissues and organs in the following order : lymphatic 
glands, liver, peritoneum, omentum and intestine, pancreas, pleura, 
lung, and spleen. The squamous variety is a somewhat flat tubular 
swelling involving the superficial layers. It may constrict the oesopha- 
geal orifice and cause atrophy of the stomach. Cases in which a can- 
cerous stomach has been removed entire during life demand special 
attention at the postmortem. 

Gastrectasis, or dilatation of the stomach, is due to : I. Pyloric 
Stenosis. — (a) Carcinoma, (b) Congenital conditions, (c) Hyper- 
trophy of the pyloric sphincter, (d) Cicatrix of an ulcer, (e) Peri- 
toneal adhesions, (f) Cancer of the head of the pancreas or other 
structure pressing on the duodenum, (g) Spasm of the sphincter. 
II. Atony of the Gastric Walls. — (a) From chronic gastritis, (b) 
Excessive ingestion of solids and liquids, (c) Traumatism, (d) Sur- 
gical intervention, (e) Serious infectious diseases. (/) Neurasthe- 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS I4I 

nia. (Hemmeter.) At first there is hypertrophy of the muscular 
walls. Soon, however, interstitial sclerosis comes on, the stomach may 
become either pyriform or hour-glass in shape, and the mucous coat is 
thrown into exaggerated folds. As atrophy advances all the layers of 
the stomach become thinner; the bundles of muscles are separated by 
connective tissue ; the surface may show evidences of pigmentation and 
petechial hemorrhage ; and while the serous surface sometimes remains 
unaltered, it is usually thick, pale, and opaque. 

Gastritis, or inflammation of the stomach: I. Acute. — (a) Errors 
in diet both as regards quantity and quality, (b) Irritant poisons. 

(c) Mechanical: external (severe injury to the epigastrium); local 
(fish-bone, etc.). (d) Thermal (hot or cold ingesta). (e) Infectious 
diseases, (f) Psychic shock (grief, sorrow, etc.). (g) Extension 
of inflammation. II. Chronic. — (a) Follows repeated acute attacks. 
(&) Slow poisons (alcohol, tobacco, gout, rheumatism), (c) Diet. 

(d) Anaemia and chlorosis. 

I. (a) In simple gastritis the mucous membrane is hyperaemic. 
swollen, and covered with profuse thick mucus. There are localized 
areas of ecchymosis and often small erosions. In severe cases there is 
considerable denudation of epithelium, with perhaps an exudate of 
grumous blood, (b) Phlegmonous or suppurative gastritis may exist 
in two forms: the abscesses may be small, multiple, and miliary, or 
they may be diffuse. The pyloric end is most commonly involved. The 
submucous layer is most extensively altered. It is swollen, cedematous, 
purulent, and sometimes even bloody. The mucous membrane over- 
lying the abscess may be normal in appearance, it may slough off, or, 
again, it may be swollen and hemorrhagic. On the other hand, the 
surface is sometimes studded with numerous areas of focal necrosis of 
a yellowish appearance, and, on section, may discharge pus.- Diph- 
theritic gastritis sometimes follows laryngeal or pharyngeal diphtheria, 
and frequently accompanies pyaemia, scarlet fever, variola, and malig- 
nant endocarditis. In this form of gastritis we find a variable number 
of circumscribed areas of false membrane firmly adherent to the under- 
lying structures and leaving a raw surface when removed. It is apt to 
attack particularly the .crests of the rugae. The diphtheritic patches are 
usually surrounded by areas of more or less pronounced congestion, 
(c) In toxic gastritis the appearance of the viscus depends upon the 
amount of contained food at the time of ingestion and the concentration 
and kind of poison. If the latter is diluted, the mucous membrane 



I4 2 POST-MORTEM EXAMINATIONS 

alone suffers; if concentrated, all the coats may be involved. Alkalies 
appear to' be more destructive than acids, the lesions produced resem- 
bling those of an intense congestion, more or less localized. In very 
severe cases perforation may follow. Sloughs or ulcers are almost 
invariably found where the poison has been concentrated. Mycotic 
gastritis may be due to: (a) Anthrax, (b) Favus. (c) Thrush. 
II. Chronic. — (a) Hypertrophic. — Virchow calls a condition of the 
mucosa when there are swelling, cloudiness, and a yellow color, gas- 
tritis parenchymatosa or glandularis; it is due to poisons, as arsenic 
and phosphorus, to acute infectious diseases, to acute atrophy of liver, 
etc. This may be localized or diffuse. In the former case numerous 
mucous polyps can be seen over the affected area. This variety occurs 
in drunkards. These warty elevations show considerable cystic degen- 
eration. In the diffuse variety the stomach is almost invariably en- 
larged and the walls are thickened, particularly the mucous coat, which 
is decidedly velvety both to sight and touch. Besides being swollen, 
rugse are often present in exaggerated folds. Petechial hemorrhages 
and areas of pigmentation are common. There are often evidences of 
previous ulcerations (cicatrices). The stomach frequently contains a 
variable quantity of thick, tenacious, sour-smelling, greenish mucus. 
(b) Atrophic. — When this variety of the disease exists the walls of 
the stomach become thinner. There is connective-tissue overgrowth, 
which by its contraction causes the epithelial cells to undergo degenera- 
tion and disappear. The mucous membrane is thin, smooth, and pig- 
mented. 

In hemorrhage from the stomach, if the blood come from without, 
as from a rupture of an aneurism, the stomach presents but few 
changes. The blood may be fluid or clotted ; it may be bright red or 
dark in color. When the hemorrhage is due to actual disease of the 
stomach, this blood is apt to be coffee-brown. Petechial hemorrhages 
in the mucous membranes are common. Extensive hemorrhage from 
the wall of the stomach is usually associated with gastric ulcer. 

PANCREAS. 

The position of the pancreas having been determined in the pre- 
liminary examination of the abdominal cavity, its isolation and detach- 
ment are attended by no difficulty unless there be disease of neighboring 
parts, in which case its removal may necessitate taking an adjacent 
viscus with it. Many students are singularly unfamiliar with the nor- 



CRITICAL EXAMINATION OF THE ABDOMINAL ORGANS 



H3 



mal anatomy of the pancreas, the splenic artery often being mistaken 
for the pancreatic duct and the sensation of hardness which this gland 
normally imparts to the touch being regarded as an evidence of scle- 
rosis ; the head and tail of the pancreas, too, are not infrequently left 
in the body and thus escape examination. Disease may extend from 
the pancreas to the portal vein, bile ducts, pylorus, or duodenum, or 
from these organs to the pancreas. Hemorrhages, tumors, degenera- 
tions, calculi, atrophic changes, cysts, etc., may be found in this organ. 
The possible presence of fat necrosis — a not infrequent cause of sudden 
death — should be borne in mind. 

The etiology of pancreatitis is practically unknown, though it is 
probably of a chemical nature. In the lower animals acute pancreatitis 
can be produced experimentally by the injection of an artificial gastric 
juice, but it is impossible to foretell which form of the disease will 
result. I. Acute, (a) Hemorrhagic, (b) Suppurative, (c) Gan- 
grenous. II. Chronic, (a) In hemorrhagic pancreatitis the organ is 
enlarged, thin, irregular in outline, and intensely congested, coagulated 
blood often appearing on the surface of the pancreas while other areas 
may be comparatively normal. The gland is somewhat harder than 
normal, but may be almost diffluent. There may be adhesions to the 
surrounding structures. The omentum and mesentery sometimes show 
focal areas of fat necrosis, whereas the serous membranes and the 
subcutaneous tissue are often the seat of various-sized hemorrhagic 
extravasations. The stomach may contain grumous blood and present 
the evidences of an acute gastritis, (b) Suppurative pancreatitis may 
follow the hemorrhagic variety or may be the result of septic infection 
from a distant focus. The pancreas appears swollen, is softer in con- 
sistence, and may be the seat of a single abscess or of numerous ones. 
It forms adhesions to surrounding structures, from w r hich it can be 
separated only with much difficulty. There may be numerous meta- 
static abscesses in other organs, (c) In gangrenous pancreatitis the 
gland may present a dry, necrotic appearance, but, as a rule, it is a dark 
slate-colored, diffluent mass, surrounded by more or less dense adhe- 
sions- with the adjacent viscera. In some cases it has been found that 
the organ has entirely disappeared, its place being taken by an abscess- 
cavity containing a foul-smelling mass. II. A chronic interstitial pan- 
creatitis exists in congenital syphilis. The pancreas is quite firm. The 
capsule is of firm consistence and gray in color. On section it crackles. 
The pancreas is diseased in fifty per cent, of the cases of diabetes 



I4 4 POST-MORTEM EXAMINATIONS 

mellitus. There may be simple atrophy, pigmentary cirrhosis, cancer, 
calculi, cystic disease, or fat necrosis. The islands of Langerhans are 
peculiarly liable to be affected. 

Retroperitoneal lymph-glands, best exposed by dividing the ver- 
tebral attachments of the mesentery at its roots, may be thickened from 
inflammation (as in syphilis) or be the seat of primary tumors (espe- 
cially sarcoma and lipoma), secondary cancer, amyloid degeneration, 
and tuberculosis, or may have undergone changes due to various other 
inflammatory, cystic, and systemic affections. 

Examination of the diaphragm may reveal the existence of hernia, 
abscess on the under surface, perforation (as in echinococcus cysts or 
amoebic abscess of the liver), trichina spiralis, inflammation of its 
serous investment, fatty degeneration and brown atrophy, hypertrophy 
(as in obstruction to normal respiration), atrophy (as in pseudohyper- 
trophic muscular atrophy), etc. 

The vena cava and the aorta should be inspected for signs of 
inflammation, thrombosis, etc. To remove the aorta it should be 
grasped as high up as possible, drawn forcibly forward, and cut 
obliquely from within and above outward and downward. In order to 
secure a firmer hold one finger may be inserted in its lumen. ( Orth. ) 

The thoracic duct, with its three- to eight-millimetre caliber, is 
situated behind and to the right of the aorta, and may be most readily 
found near the diaphragm. It can be opened by slitting with a pair of 
fine scissors. 

Abscesses in the psoas muscles may be secondary to Pott's disease, 
coxitis, perforation of the intestine, tumors, etc. Examine the spinal 
column for kyphosis, lordosis, and scoliosis. 

In death from fright and chloroform narcosis, a large amount of 
blood is collected in the abdominal veins as the result of vasomotor 
paralysis. 



CHAPTER XII 

DISEASES OF THE KIDNEY 

No little confusion exists in the description of the pathological 
lesions of the kidney owing to the multiplicity of terms employed. I 
have long been in favor of the following classification of renal diseases, 
which depends upon the structure affected: I, epithelial (parenchyma- 
tous) nephritis; 2, fibrous (interstitial) nephritis; 3, vascular ne- 
phritis. It should be borne in mind that there is no such thing as a 
perfectly pure form of nephritis and that the condition which predomi- 
nates gives the name to the lesion. For example, when we speak of 
parenchymatous nephritis, we do not mean that the epithelial cells alone 
are affected without involvement of the connective tissue, for it is 
entirely proper to describe a case as chronic parenchymatous nephritis 
in which the interstitial changes are beginning to predominate. The 
epithelial cells of any portion of the kidney may be affected primarily, 
hence the name glomerulo-nephritis, etc. 

Amyloid Changes. — These may be due to (a) prolonged suppu- 
ration (tuberculous or syphilitic), (b) chronic disease of the kidney, or 
(c) lack of cardiac compensation. The amyloid kidney is usually 
enlarged (the condition occasionally occurs in a contracted kidney), 
pale in color, and firm in consistency. The capsule is adherent in places 
and shows petechial hemorrhages beneath it. The cortex is increased 
in size. The glomeruli are first affected and usually prominent, 
although the cortex is pale in contrast to the somewhat reddish color of 
the pyramids. The organ has a bacony or waxy appearance. The 
urine contains albumin. The tube-casts are hyaline, waxy, or finely 
granular. (Edema of the extremities is common. 

Congenital Defects. — ( 1 ) Total absence. (2) Absence of one, 
with hypertrophy of the other. (3) Rudimentary, cystic. (4) Du- 
plication. (5) Partial coalition, usually lower end (horseshoe). 

Congestion. — (a) In traumatism the kidney is large; the capsule 
is tense; the color is dark red. On opening the capsule the contents 
are found to be soft and bulge out and blood drips freely from the sur- 
face of the section. The dependent portions are more congested than 
the cortex. In passive congestion the organ is enlarged and firm ; the 
capsule strips off readily ; the cortex is wider than normal ; the surface 

10 145 



146 



POST-MORTEM EXAMINATIONS 



on section looks coarse and connective tissue is plainly visible; the 
cortex is of a deep-red color and the pyramids are of a purple-red. 
Congestion may be due to (b) drugs, as cantharides or turpentine, (c) 
infectious fevers, (d) alterations of the circulation in the kidney itself 
or in the vena cava (rare), (e) valvular lesions of the heart, (f) dis- 
eases of the liver, or (g) diseases of the lungs. 

Cystic Disease. — (a) Congenital cystic kidneys are greatly en- 
larged, so much so at times as to impede labor. There may be a con- 
glomeration of cysts varying in size from that of a pea to a small apple. 
In some cases no renal tissue can be seen without the aid of a micro- 
scope. The cysts are lined with flattened epithelium and contain a 
fluid in which are found albumin, blood-crystals, cholesterin, triple 
phosphates, and fat-drops, (b) Chronic nephritis (which see), (c) 
Adenocystomata, of similar origin as the corresponding cysts in the 
ovary, (d) Concretions block up the uriniferous tubules and press 
upon the still intact epithelial cells, which later become flattened and 
disappear. The stroma and vascular supply are next affected and a 
cystic condition is produced, or the disease may go on to the forma- 
tion of large concretions. 

Hydronephrosis. — The outflow of liquid from the pelvis of a 
kidney may be obstructed by (a) congenital deformities, as when the 
pelvis comes off too high up on the kidney, (b) twists of the ureter, 
(c) calculi, (d) morbid growths, or (e) cicatricial bands. There is an 
accumulation of non-purulent fluid, which by steady pressure produces 
an atrophy of the organ and a gradual distention of its pelvis. The 
papillae become more flattened and disappear, and their place is taken 
by concave recesses in the medulla, which becomes narrower. In ex- 
treme cases the kidney may be converted into a large cyst with some 
imperfect septa. There may be an enormous quantity of the contained 
fluid or only a few ounces. It is yellowish in color and contains urea, 
uric acid, and sometimes albumin and sugar. There is usually com- 
pensatory hypertrophy of the opposite kidney. 

Infarcts. — (a) Calcareous infarcts extend through the tips of the 
papillae as stripes through one-half or more of the medulla, mainly 
along the canals, but also in interstitial tissue. There is effervescence 
on the application of hydrochloric acid, (b) Uric acid — found as acid 
ammonium urates in very young children and as acid sodium urates 
in mature years in cases of gout — may be deposited within the kidneys 
in the form of flakes (uric acid nephritis or gouty kidneys). In babes 



DISEASES OF THE KIDNEY 



H7 



they appear as yellow radiations from papillae into medulla, and show 
that the child was born alive, as they occur only after breathing has 
taken place. Sodium hydrate dissolves the acid ammonium urates, 
(c) Haemoglobin occurs in haemoglobinuria. It exists in the canals 
first as lumpy brown, later as granular, and seldom as crystalline 
masses. Haematoidin crystals are seen where old hemorrhages were 
(Virchow). (d) Bilirubin infarct gives the bile reactions. It occurs 
in the icterous new-born, in acute atrophy of the liver, and in pro- 
gressive pernicious anaemia, (e) Infarcts caused by salts of silver are 
very rare. 

Interstitial Nephritis. — In acute interstitial nephritis the whole 
kidney is increased in size; the color is uniform, making it hard to 
distinguish the border line between the cortex (which is swollen) and 
the medulla. The process is essentially a productive one. There is a 
marked migration of the leucocytes and the connective tissue undergoes 
proliferation. The cells increase in number and the intercellular sub- 
stance disappears. The pus-cells get between the epithelial cells and 
the lumina of the canals can no longer be followed. Such areas may 
be found anywhere in the kidney substance. The process is essentially 
due to pyogenic bacteria brought from the heart, as in malignant endo- 
carditis, or the uterus, as in puerperal sepsis. The process ends in 
abscess formation, often affecting the perinephric tissues. (Langer- 
hans.) A similar condition may start from without the kidney or 
extend up from the pelvis or further down the urinary tract. 

Chronic interstitial nephritis may start as an acute form, but most 
frequently affects alone the connective tissue of its stroma, the blood- 
vessels not being involved. The process naturally ends in contraction. 
The canals are freed from their epithelial cells and the glomeruli may 
be brought so close together as to touch each other. The capsule is 
adherent and the surface lumpy or granular and grayish red in color. 
The cortex is much smaller and may measure only a few millimetres 
in thickness, but its consistence is markedly increased. Compensatory 
hypertrophy may occur. If the canals are fatty they appear as yellow 
stripes or points. Cysts are common and are most marked at the junc- 
tion of the cortex and medulla. The vessel walls are thickened. Local- 
ized interstitial nephritis is usually syphilitic, while the diffuse form is 
due to gout, lithaemia, lead, over-indulgence, etc. In the latter form 
we have granular atrophy, the so-called red granular kidney, in which, 
as contraction takes place, cysts are found. 



148 



POST-MORTEM EXAMINATIONS 



Movable Kidney. — (a) Female sex. (&) Absorption of peri- 
nephric fat. (c) Repeated pregnancies. (d) Traumatism. (<?) 
Displacement by tumors. As a rule, the displacement is not great. The 
kidney usually moves downward or upward and inward, generally 
rotating so that the outer border and upper end move forward and the 
hilum is directed inward and backward. Nearly all cases are associated 
with a medial displacement of the colon. The right kidney is the one 
most frequently affected. 

Parasites. — Of the parasites the following are found: (a) Dys- 
tonia haematobium (Bilharzia haematobia). (b) Filaria sanguinis 
hominis. (c) Echinococci. (d) Cysticerci. (e) Pentastoma. (/) 
Strongylus gigas. All are rare in this country. 

Parenchymatous Nephritis. — Acute diffuse inflammation of the 
kidney is due to: (a) Acute infectious fevers, (b) Poisons, — e.g., 
turpentine, arsenic, etc. (c) Traumatism, (d) Exposure to cold and 
wet. Macroscopically the organ is swollen, tense to the touch as the 
capsule is stretched, but the substance of the kidney is softer than 
normal, the color is gray to yellowish, and the stellate veins on the 
surface are prominent. The capsule strips off easily and is somewhat 
thinner than normal. On slitting the capsule the contents of the kidney 
bulge out. The cortex, which is increased in amount, is somewhat 
pale, swollen, and soft ; the glomeruli appear as minute red dots. The 
pyramids are distinct and striated. The radiations in the medulla may 
be gray or transparent, gelatinous or watery. The larger blood-vessels 
are overfilled and prominent. 

Parenchymatous Nephritis, Subacute. — The large white kid- 
ney is more swollen than in the acute form and the tissue itself is of 
greater consistency. The cortex may be increased, therefore, before 
contraction commences. Yellow spots where the degenerative changes 
are most marked are found in the gray glossy substance. Cysts are 
absent, unless interstitial changes are associated. The kidney is dry 
on section, and the pyramids of the medulla show reddened stripes 
pointing towards a papilla. This condition may be associated with 
amyloid degeneration, most marked in the glomeruli. The mucous 
membrane of the pelvis is frequently swollen and of a pinkish color. 
Microscopically the changes are those of an acute diffuse inflammation, 
including cloudy swelling, proliferation, desquamation, and a granular 
change in the cells lining the tubules. The straight connecting tubules 
may entirely escape, though there is a form of catarrhal nephritis, 



DISEASES OF THE KIDNEY I ^g 

usually of an ascending variety, in which this part of the kidney is 
alone affected. In the surgical kidney there is an acute parenchymatous 
nephritis with abscess formations. Each individual cell is larger, the 
transverse diameter of the tubule increased, and the lumen diminished 
or even obliterated. Death most frequently takes place before the 
degenerative changes are complete; otherwise resorption and contrac- 
tion follow, and on the surface there are slight indentations, often asso- 
ciated with a hemorrhagic condition, hence bloody casts, as in poisoning 
by cantharides and potassium chlorate, where even pigmentary infarcts 
may be found. The urine is scanty, high colored, albuminous, and 
contains casts and free blood. There may be extensive oedema, with 
effusions into the serous cavities. 

Parenchymatous Nephritis, Chronic. — This process is latent 
and runs a slow course, often of years ; not all of the kidney is affected 
at once, some portions showing normal parenchyma while at other 
places degenerative changes are going on and at still others degenera- 
tion is complete and the parts are already in an atrophic condition. 
The cortex contracts irregularly, and has not the regular granular 
appearance seen in the kidney affected with interstitial nephritis 
( Langerhans ) , nor is there much increase in the stroma except at those 
places where contraction has taken place. 

Perinephritis Abscess. — (a) Traumatism. (&) Extension of 
inflammation from the kidney or from neighboring organs, (c) Per- 
foration of the bowel, (d) Infectious fevers, particularly in children. 
The kidney is surrounded by pus, especially posteriorly. The abscess- 
cavity is usually extensive. The pus is often offensive and may have a 
distinctly fecal odor. It may burrow and discharge into the lung, 
bowel, peritoneum, or bladder, or it may follow the psoas muscle and 
appear in the groin. 

Pyelitis and Pyelonephritis. — (a) Tuberculosis, (b) Infec- 
tious fevers, (c) Calculi, (d) Cystitis, (e) Tumors. (/) Drugs. 
(g) Cold and wet. Classification. — (a) Simple catarrhal, (b) Puru- 
lent, (c) Hemorrhagic, (d) Calculous. In simple acute pyelitis the 
mucous membrane of the pelvis is swollen, hemorrhagic, and turbid. In 
the purulent form the mucous membrane is swollen and covered w T ith 
a cream-like exudate of a yellowish or yellowish-green color. Ecchy- 
moses are common. The kidney itself is enlarged, softened, cedematous, 
grayish in color, and shows little distinction between cortex and 
medulla. Areas of necrosis or miliary abscesses are distributed through 



!^o POST-MORTEM EXAMINATIONS 

the kidney substance. The kidney may attain the size of a human head. 
It is usually firmly adherent to the adjacent organs, tissues, and vessels. 
A quart of pus may be contained in the cavity; in these extreme 
cases all appearance of the gland substance may be lost. The hemor- 
rhagic variety occurs in anthrax, sepsis, and leukaemia. In calculous 
pyelitis the mucosa is roughened, grayish in color, and thickened. 
There are also more or less dilatation of the calyces and flattening of 
the papillae. These may be covered by a gray membrane. After the 
renal substance has been destroyed, if the pelvic orifice is still obstructed, 
the pus may become inspissated and ultimately impregnated with lime 
salts. 

Stones. — The following varieties of stone may be found in the 
kidney or its pelvis : (a) Oxalate. This is very hard, dark, brownish 
yellow or gray in color, with rough surface and mulberry shaped. ( b ) 
Uric acid. This is usually smooth or a little rough, light brownish 
yellow in color and often striped, and of medium consistence, (c) 
Phosphate stones are white, crumbling, and chalky, (d) Cystin and 
xanthin stones are rare. 

Tumors. — (a) Fibromata are the most common of benign tumors. 
(b) Lipomata. (c) Myxomata. (d) Myomata. (e) Angiomata. 
(/) Lymphadenomata (or lymphomata). (g) Rhabdomyomata. 
( h ) Carcinoma may be primary or secondary ; it is comparatively rare. 
The cancer may infiltrate the whole cortex or may be knotty and sepa- 
rated sharply from the surrounding tissue. (i) Sarcoma may be 
primary or secondary. It is more common than cancer, usually occurs 
in children, and may attain to an enormous size. Here it exists as a 
myosarcoma. (/) Carcinoma sarcomatodes, (k) Patches of adrenal 
tissue may start growing and give rise to large tumors, the so-called 
hypernephroma heterotopes. Such growths are by no means rare. 



CHAPTER XIII 

DISEASES OF THE BLADDER, FALLOPIAN TUBES, OVARIES, UTERUS, 
VAGINA, AND TESTICLES 

Bladder. — The color of the mucous membrane is normally a pale 
gray, but is red in recent inflammation and blackish red if the inflam- 
mation be very severe. The mucous membrane may be cedematous and 
especially hypersemic after the ingestion of certain poisons, 'as phos- 
phorus and cantharides. It is also subject to necrosis, abscess, gan- 
grene, and tuberculosis. The veins may be distended, especially when 
hemorrhoids exist and venous thrombosis occurs. The mucosa affords 
a favorite location for the growth of various organisms and a great 
many of the pathogenic bacteria are found. Thus, typhoid bacilli may 
frequently be detected in the urine of patients suffering from typhoid 
fever. Cystitis caused by the colon bacillus may give the agglutinative 
reaction in a dilution of one to fifty of the blood of a patient suffer- 
ing therefrom. Cystitis is due to: (a) Irritants in the urine, (b) 
Extension of inflammation from adjacent parts, (c) Traumatism. 
(d) Septic infection through the blood or the urethra, (e) Infectious 
diseases. (/) Stricture of the urethra, (g) Enlarged prostate, (h) 
Diseases of the cord (myelitis). In acute cases the mucous membrane 
is swollen, reddened, and covered with a thin film of mucus or pus. 
When hemorrhage has occurred, the surface of the membrane is of a 
universal gray tint, or mottled with gray, black, or reddish-brown 
patches. In severe cases necrosis, abscess, or even perforation may 
occur. In the diphtheritic form of the disease necrotic patches are 
seen and small hemorrhages in the region of the trigone and the sur- 
rounding fundus. These increase in size. There is submucous swell- 
ing, which subsequently becomes infiltrated with pus. The whole 
mucous membrane over it degenerates and can easily be removed from 
the muscular coat. In chronic cystitis the bladder may be enlarged, 
but it is often smaller than normal. The various coats are much 
thickened and there may be true hypertrophy of the muscular coat. 
This condition is best seen in cases of long-standing chronic cystitis, 
where the inner surface may be thrown into folds and roughened so 
that the picture resembles that of the interior of a heart, and shows 
how difficult it is for injections into the bladder thoroughly to cleanse 



I52 POST-MORTEM EXAMINATIONS 

the walls in cases of inflammation. In severe cases the inner coats 
often feel rough and sandy to the touch from encrusted salts. There 
is a considerable variety of tumors in the bladder; they frequently 
assume the form of polyps and villi. Cavernous angiomata are met 
with, also dermoid or echinococcic cysts. Pockets (diverticula) may 
develop in the walls of the bladder, sometimes being covered only by 
the peritoneum. Their openings may be very small, though the size 
of each diverticulum may reach that of a hen's egg. These pockets 
are at times produced by and may contain stones. In exstrophy the 
inner surface of the bladder is exposed externally above the pubes 
through a hiatus in the median abdominal wall. Professor Guiteras 
once related to me an interesting case of primary diphtheria upon 
this exposed mucous membrane. In hypertrophy dilatation of the 
cavity exists along with increase in the thickness of the wall, which 
may reach an inch or more. The female bladder may become inverted 
and appear through the urethra. It may also take part in herniae of 
various forms. The bladder may be ruptured by external violence 
without any sign thereof being visible. In overdistention from hemor- 
rhage the bladder may reach to the umbilicus or may open into the 
rectum or vagina (vesicorectal or vesicovaginal fistula). 

In the interesting condition called trichosis vesicae the hair is 
usually referable to the breaking of a dermoid cyst into the bladder 
or to the growing of hair from the mucosa itself. In one case — an 
autopsy on a female — I could not see where the dermoid had arisen 
unless in the walls of the bladder itself. In a body examined at the 
Pennsylvania Hospital a bundle of hair was found which had become 
encrusted with salts and formed a calculus. 

Vesical calculi may contain any of the normal or abnormal con- 
stituents of the urine. If this liquid be allowed to stand, precipitation 
occurs, the character of which depends upon the acidity or alkalinity 
of the urine. Bacteria in the body may cause an alkaline decomposi- 
tion, with the formation from urea of carbon dioxide and ammonia, 
which uniting with the uric acid forms ammonium urates and triple 
phosphates. The most important sediments are uric acid, sodium 
urate, ammonium urate, — all of which give the murexide test, — 
calcium oxalate, calcium carbonate, calcium diphosphate, calcium tri- 
phosphate, and triple phosphate. Concretions may be found in the 
form of sand or as calculi. They are held together by an albuminous 
or cement-like substance, to which may be added cast-off epithelial 



DISEASES OF THE FALLOPIAN TUBES ^3 

cells, shreds of tissue, blood, mucus, etc. Primary stone formation 
ma}- take place in urine which has not undergone decomposition ; such 
calculi are composed of uric acid and urates. Secondary stone forma- 
tion occurs in an alkaline urine, the starting-point being a foreign body 
introduced through the urethra from without or a small calculus 
which has found its way down from the kidney; these stones are 
composed of ammonium urates and phosphates. They often consist 
of different substances concentrically arranged. Metamorphosed 
stones are produced where, for example, a primary stone has been 
partially dissolved by the action of an alkaline menstruum and the 
remainder covered by secondary deposits. Calculi assume a large 
number of shapes and differ much in their size. (Schmaus.) In 
addition to those named above, cystin and xanthin stones exist. Para- 
sites in the bladder are rare. The following have been found : ( a ) 
Distoma haematobium (Bilharzia hcematobia) . (b) Filaria sanguinis 
Iwminis. (c) Echinococci. (d) Cysticerci. (<?) Pentastoma. (f) 
Eustrongylus gigas. 

Fallopian Tubes. — I have seen the oviduct lengthened to over 
ten inches by the growth of a uterine fibroid, and have observed in 
the tube extra openings supplied with fimbriae, the presence of which 
might at times have an important bearing upon the question of ectopic 
pregnancy. This dangerous condition may occur anywhere within the 
tube, or the fecundated ovum may escape into the abdominal cavity 
or become caught in a corpus luteum of either ovary. It is doubtful 
whether a pure form of ovarian extra-uterine pregnancy exists; in 
cases so diagnosed which have been brought to me for examination 
careful study showed that fecundation occurred near the ostium, and 
the fimbriated extremities became attached to the ovary just as in a 
case of ovarian abscess, making it to appear as if the pregnancy had 
started in the ovary. An interesting abnormality is lithopaedion, w T here 
a foetus may remain in the abdominal cavity for thirty or forty years 
with certain of its tissues still in a condition to be readily recognized. 
The convoluted interior of the oviduct offers a favorable place for the 
growth of various organisms, and the tube itself may be affected with 
many kinds of benign- and malignant tumors, the latter being primary 
or metastatic. It is subject to hemorrhages and different forms of 
inflammation. In catarrhal conditions the tube may rupture and give 
rise to general peritonitis. It is very apt to be bound down to the 
adjacent parts by adhesions. 



!54 POST-MORTEM EXAMINATIONS 

In salpingitis the Gonococcus, the Streptococcus, the Bacillus coli 
communis, etc., are found. Classification. — (a) Hydrosalpinx, (b) 
Pyosalpinx. (c) Hematosalpinx, (d) Proliferous salpingitis, (i) In 
acute salpingitis the Fallopian tubes are swollen. The neighboring 
blood-vessels are dilated, tortuous, and overfilled with blood. There is 
often considerable exudate on the serous surfaces, causing adhesions of 
the tubes to the surrounding structures. On section the lumen of the 
tubule is found to contain serous, mucopurulent, or hemorrhagic fluid. 
The mucous membrane is thickened, swollen, and often intensely con- 
gested. To show the ciliated cells, though these may have been shed 
by the inflammatory process, care must be taken to harden the tissue 
at once after removal and in the same manner as to show karyokinesis. 
(2) In chronic (proliferous) salpingitis the tubes become enormously 
thickened, hard, and resistant to the touch. The adhesions to surround- 
ing tissues are very marked and more or less completely organized. The 
new connective tissue contracts, throwing the organs out of their proper 
relation and often obliterating the normal appearance of these parts. 

Ovaries. — These show perhaps more pathological changes than 
any other part of the body. The ovary may be divided into lobes by 
bands of connective tissue, or actual duplications of the parts may 
occur. It may form part of a hernia, and in a child I have found it in 
the canal of Nuck. As the opportunity arises, study the differences 
between a true and a false corpus luteum and a corpus hsemorrhagi- 
cum. The ovaries are subject to various forms of inflammation, an 
entire organ at times being converted into a pus sac. They are often 
bound down by adhesions and in later life undergo senile atrophy and 
may even become calcareous. Among the tumors here found may be 
mentioned adenomata, dermoid cysts, which are of an almost endless 
variety, enchondromata, endotheliomata, fibromata, fibrorhyomata, 
myomata, cancers, cystomata, sarcomata, psammocarcinomata, etc. 
Ovarian cysts may grow to an enormous size and contain even a hun- 
dred pounds of fluid. 

Uterus. — In examining the womb notice any abnormalities on the 
exterior and be sure to search every portion of the interior for any 
lesions which may exist. The situation of the organ may be markedly 
altered, both as a whole and as to its individual parts. Thus, we may 
discover anteflexion, anteversion, retroflexion, retroversion, prolapse, 
inversion, dilatations, elongations, bendings, or even find it forming 
part of an inguinal or a crural hernia. The chief congenital malforma- 



DISEASES OF THE UTERUS I55 

tions are uterus bicornis, bicornis duplex, bilocularis, subseptus, and 
bipartitus. The uterus is subject to atrophy, hypoplasia, atresia, and 
hypertrophy. Uterine tumors are of great variety, — adenoma, adeno- 
cystoma, cancer, deciduoma malignum, hsematoma polyposum, fibroma, 
myoma, myofibroma, myosarcoma, etc. A placental polyp may assume 
destructive characteristics. Hemorrhages are common, and, besides 
those due to menstrual disturbances, are found associated with polyps, 
cancer, etc. After parturition and after the menopause marked changes 
take place in the blood-vessels, which may undergo amyloid degenera- 
tion. Infarcts are seen. Many varieties of endometritis exist, such as 
gonorrhceal, tuberculous, diphtheritic, decidual, fibrous, gangrenous, 
glandular, interstitial, catarrhal, purulent, mycotic, villous, etc. Lan- 
gerhans describes an interesting case of an old woman in which the 
uterus was so enlarged by a solid mass of thrush fungi and other bac- 
teria that it measured some two inches in diameter. The uterus may 
rupture, as from childbirth, trauma, etc. 

In acute forms of endometritis the mucous membrane is red, 
swollen, and sodden ; the discharge is profuse, stringy, and often puru- 
lent ; in severe cases blood is present. As the result of contusion during 
labor, plus infection, there may develop a suppurative process which 
transforms the parts into a soft, stinking, grayish-green or brown mass 
that tends to become gangrenous. The cervix is the most often in- 
volved. In diphtheritic endometritis there is formed a thick grayish- 
yellow or white membrane, the decidua lying loosely on the surface. 
This process may begin and remain at the placental insertion or may 
involve the cervical portion of the uterus. The infection may spread 
through the lymph stream or blood-vessels. Acute (ulcerative) endo- 
carditis is a frequent complication of puerpural infection. In hemor- 
rhagic endometritis the mucous membrane is red from engorgement 
of blood-vessels and numerous punctiform hemorrhages. It is distin- 
guished from a similar appearance in menstruation by the condition of 
the ovaries. 

In chronic hypertrophic endometritis there is a hyperplasia of the 
mucosa with softening and congestion, forming polypoid excrescences ; 
the glandular structures also hypertrophy, become occluded, and form 
cysts of various sizes. In the cervix enlarged Nabothian cysts should 
be looked for. In atrophic endometritis the mucous membrane becomes 
thin and pigmented and the glandular structures disappear. Follicular 
erosion of the cervix occurs after lacerations. 



156 



POST-MORTEM EXAMINATIONS 



Vagina. — The vagina may be wholly or partially divided by a 
longitudinal septum. It may be entirely closed or so small that if coitus 
be attempted it takes place through the urethra, which thus becomes 
markedly dilated. The normal flora is considerable, and of pathogenic 
organisms the Gonococcus, Bacillus diphtheria, and Oidium albicans 
(thrush) are of importance. It is well to remember that diplococci 
other than the Gonococci are frequently found in the vagina. Severe 
inflammation may exist, and even gangrene may supervene. It is sub- 
ject to numerous tumors, and malignant neoplasms of the cervix uteri 
may by extension of the growth involve the vaginal walls, which 
should, therefore, always be examined in such cases. 

Testicles. — The testes are subject to many lesions, but the exposed 
situation and extremely specialized character of these organs are suffi- 
cient to account therefor. The testicles may be found undescended, and 
in such cases are peculiarly liable to injury and the subsequent develop- 
ment of tumors. They may be malformed or duplicated, and when 
one is removed the other may undergo compensatory hypertrophy. 
They may be affected by syphilis, tuberculosis, leprosy, etc. In guinea- 
pigs infected with glanders the testes are especially apt to become 
diseased. It is often impossible to tell whether a tumor originating in 
these organs is a sarcoma or a cancer. Dermoids and mixed neoplasms 
containing cartilage are not uncommon. Hemorrhage may take place 
into the tunica vaginalis and the testicle may atrophy owing to pressure 
from the fluid in a hydrocele. In typhoid fever the condition of the 
testes should always be noted, as they may become infected with the 
typhoid bacillus. True abscesses are found in them, and they may 
undergo brown atrophy, glycogenic infiltration, pigmentary or amyloid 
changes. In elephantiasis they may show hypertrophy. The cords 
sometimes rupture, and varix is common. I have seen the duct tortuous 
and calcified. 



CHAPTER XIV 

DISEASES OF THE LIVER AND GALL-DUCTS 

Acute Yellow Atrophy. — This is an acute disease of the liver, 
presumably of infectious origin, characterized by a rapid fatty degen- 
eration of the organ, with invariably fatal termination. Due to: (a) 
A specific micro-organism ( ?). (b) The ordinary micro-organisms of 
suppuration and infectious diseases have been found in this condition, 
(c) Certain poisons, — e.g., phosphorus, (d) Female sex. (e) Preg- 
nancy or the puerperium. The liver is greatly reduced in size, — one- 
half to one-third ; in one of my cases, however, the condition had been 
preceded by hypertrophic cirrhosis and the organ weighed over five 
pounds. The liver is thin, flattened, and flabby, the capsule is wrinkled, 
and the gland is of a pale-yellow color. Both on the surface and on 
section may be seen a number of orange-yellow patches, in the centre 
of which are usually marked hemorrhagic areas. The remainder of the 
liver is of a yellowish-brown or mottled color. The outlines of the 
lobules are very indistinct. The bile ducts and gall-bladder are empty. 
Bilirubin crystals may be seen under the microscope. If a section of the 
liver be allowed to remain in the air for some time, a thin, white coating 
appears on its surface, which on examination is found to consist of 
crystals of leucin and tyrosin. The adjacent organs are usually stained 
with bile and present numerous hemorrhages, especially on the surface. 
The spleen is enlarged and the heart and kidney show marked granular 
change. The color of the liver in acute yellow atrophy depends on the 
time at which death took place : in the earlier stages the organ is ochre- 
yellow, in the later stages it is mottled, and if much blood be present it 
is grayish red. 

Amyloid Degeneration. — Found in cases of: (a) Prolonged 
suppuration, tuberculous or syphilitic, (b) Infectious fevers. (c) 
Chronic visceral diseases with cachexia. The liver is large in size, 
smooth in outline, and- pale in color. The edges are distinctly rounded ; 
small hemorrhages are common on the surface. On section the surface 
is anaemic, semi-transparent, and infiltrated. It presents the character- 
istic lardaceous or waxy appearance. The process may be a localized 
or a generalized one; in either case staining by Lugol's solution is 

157 



158 POST-MORTEM EXAMINATIONS 

never uniform, as the diseased brown spots appear only in certain areas. 
The characteristic coloration may be seen upon the lining of both 
hepatic and portal vessels. Early in the disease this reaction is hard to 
detect, except by special stains under the microscope. Very thin pieces 
of the liver should be sectioned with a scalpel and put in a small glass 
dish. Add a solution of iodine and then wash out with water. Put 
something white under the dish and the characteristic coloration can 
be more readily seen. 

Cancer. — I. Secondary Cancer. — Most common. Histologically 
shows same structure as primary growth, which is usually in the 
stomach, bowel, or pancreas. The liver is enormously enlarged, irregu- 
lar, and nodular. The nodules are usually symmetrical, often super- 
ficial, flattened, discrete, and umbilicated; they may be more or less 
evenly distributed throughout the liver. On section whitish masses of 
varying size are seen, contrasting with the red color of hepatic tissue, 
the yellow staining of bile, pigmentation due to blood, and the light- 
yellow areas of fatty degeneration. The cancerous masses may undergo 
fatty degeneration, suppuration, or fibroid change. II. Primary Can- 
cer. — Rare, (a) Massive. Causes great enlargement. On section the 
mass is uniform grayish white in color, somewhat firm, and distinctly 
outlined from the liver substance, (b) Nodular. Large and small 
nodules are scattered throughout the organ. These usually consist of 
a primary growth and numerous secondary nodules, (c) Cancer with 
cirrhosis is rare. Liver not much enlarged. Surface of section is 
grayish yellow, studded with nodular yellowish masses. In one of my 
cases of primary cancer of the gall-bladder the cancerous portions and 
the liver had become infected by the Bacillus pyocyaneus. 

Cholecystitis, Acute Infectious. — There exists an acute in- 
flammation of the gall-bladder due to: (a) The introduction of pyo- 
genic micro-organisms, — for example, the Bacillus coli communis and 
the typhoid bacillus, pneumococcus, staphylococcus, and streptococcus. 
(b) Gall-stones, (c) Extension of inflammation from the bile ducts. 
The gall-bladder is distended ; its walls are thickened and tense. The 
mucous membrane is swollen, hypersemic, and may be covered with a 
purulent exudate. The submucosa may also be involved. The contents 
of this sac are cloudy and dark in color, and may be mucopurulent or 
hemorrhagic. Orth states that the inflammation is usually of a necrotic 
character. The tissue is of a dirty yellow-brown color and sometimes 
is rotten and easily torn. Gall-stones are frequently present. The 



DISEASES OF THE LIVER AND GALL-DUCTS 159 

cystic duct is often obliterated. There may be adhesions with the bile 
duct or omentum. 

Cholelithiasis. — Gall-stones may be formed within the gall-blad- 
der or in the ducts leading to or from it. Consider: (a) Most fre- 
quent in females, (b) Age, fifty per cent, over forty years old. (c) 
Sedentary habits, (d) Overeating, (e) Carcinoma( ?). (1) The 
calculi are usually multiple, rarely single. They vary in size as well as 
in number. When multiple they are faceted, sometimes mulberry- 
shaped. They are of a dark bluish or greenish color. On section there 
is a nucleus consisting of epithelium, rarely a foreign body, then comes 
a layer of inspissated bile-salts, the outer covering being cholesterin. 
There may also be bile-acids, fatty acids, salts of calcium and magne- 
sium, with a trace of iron and copper. When the stones consist of 
pigment exclusively, they are very easily broken and vary from yellow- 
ish brown to black in color. When composed of cholesterin entirely, 
they are softer, easily indented with the finger-nail, but not brittle, and 
are crystalline, the crystals forming layers. They are colorless and 
more or less transparent, but turn blue when iodine and sulphuric acid 
are added. They generally consist of both pigment and cholesterin, 
which may be combined or may be separated by layers. These stones 
are usually firm in consistence, rarely friable. (2) The gall-stones 
may lead to impaction of the gall-bladder or to" obstruction of the cystic 
and common ducts or even of the bile duct alone. There may be forma- 
tion of a fistula, external or internal, with escape of bile. The bladder 
itself is much thickened, sometimes dilated, sometimes smaller than 
normal through chronic inflammation. 

Cirrhosis. — Under this heading are classified various forms of 
disease of the liver characterized by a marked increase of its connective 
tissue, which may be capsular, interlobular, or intralobular, with or 
without increase or decrease in the size of the organ. Causes: (a) 
Alcohol, (b) Certain infectious diseases, — e.g., syphilis, tuberculosis, 
malaria, scarlet fever. (c) Micro-organismal infection. (d) Me- 
chanical obstruction to the onward flow of the blood, (e) Rickets. 
(/) Anthracosis. (g) Poisons, as phosphorus and cantharides. -Clas- 
sification. — (a) Alcoholic, (b) Fatty, (c) Hypertrophic, (d) Cap- 
sular, (e) Syphilitic. (/) Cyanotic, (g) Malarial, (h) Scarla- 
tinal, (i) Tuberculous. (;') Rhachitic. (k) Anthracotic. (1) In 
the atrophic cirrhosis of Laennec the organ is greatly reduced in size, 
although in the beginning it may be slightly enlarged, and later is 



!6o POST-MORTEM EXAMINATIONS 

altered in shape. The surface is irregular and nodular and the capsule 
thickened. The nodules are usually small, but in some cases they may 
be greatly increased in size. The tissue is firm, hard, and resistant to 
the knife. The surface of section presents a mottled appearance, the 
lobules being divided by bands of connective tissue. The liver sub- 
stance itself is of a yellowish or greenish-yellow color. The areas of 
connective tissue which are periportal are gray. (2) In fatty cir- 
rhosis, found usually in drunkards, the organ is enlarged, somewhat 
smooth, although often slightly granular. It is paler than normal and 
of a yellowish-white color. It is firm and resistant to the knife. The 
capsule is opaque and often much thickened. The peritoneal cavity 
usually contains ascitic fluid. The membrane is opaque and thickened. 
Chronic involvement of the stomach and small intestine is always pres- 
ent. The spleen is enlarged; the kidneys are often cirrhotic. Owing 
to interference with the portal circulation by the cirrhotic liver, exten- 
sive compensatory circulation is formed. The abdominal vessels above 
and below the umbilicus are markedly enlarged. Around the umbilicus 
is found the caput of Medusa. Acute tuberculosis of the peritoneal 
cavity is not infrequently associated. (3) Hypertrophic cirrhosis is 
most common in young men. Ackerman compares it to elephantiasis. 
The organ is enlarged, but the outline is normal. The surface is usually 
smooth and its color an olive-green; the consistency of the organ is 
increased and the capsule is thickened. The surface of section is uni- 
formly greenish yellow and the lobules may be separated by distinct 
bands of connective tissue. The spleen is greatly enlarged. Jaundice 
is a marked symptom of this disease. Ascites is usually absent. (4) 
In capsular cirrhosis there is enormous thickening of the capsule, which 
is irregular and somewhat wrinkled, producing great contraction of the 
liver. The organ itself is rarely markedly cirrhotic, its tissue being 
usually soft. Chronic capsulitis of the spleen, chronic perisplenitis, and 
ascites are often present. The kidneys usually show granular change. 
(5) In syphilitic cirrhosis the liver is markedly irregular in shape, 
being divided into peculiarly shaped lobes by extensive bands of fibrous 
tissue traversing the organ in indefinite directions. In one of my cases 
over forty distinct lobulations were present. The cut surface is mottled, 
often fatty in appearance, and shows the presence of gummata or of 
syphilitic scars. The connective-tissue bands are of a gray or reddish- 
gray color. (6) For cyanotic cirrhosis see Passive Congestion of the 
Liver. (7) In malarial cirrhosis the liver is markedly enlarged, com- 



DISEASES OF THE LIVER AND GALL-DUCTS ^i 

monly extending to the level of the umbilicus. It is firm in consistence, 
of a dark-red color, smooth in outline, and bleeds freely on section. 
(8) Klein has pointed out that chronic interstitial hepatitis may follow 
an attack of scarlet fever, which may account for some cases of cirrhosis 
of the liver in children. (9) Rhachitic cirrhosis is a form of the dis- 
ease in which there is a marked increase of connective tissue around the 
individual lobules. (10) Anthracotic cirrhosis occurs in coal-miners, 
in whom the coal-dust may occasionally reach the liver in sufficient 
quantities to cause a marked connective-tissue formation about the 
portal canal. ( Welch. ) 

Congestion. — (a) Acute infectious diseases. (&) Traumatism, 
(c) Extension of inflammation, — e.g., from the intestines, (d) Val- 
vular heart-disease, (e) Pressure of tumors. (/) Other mechanical 
obstructions to the circulation. The condition is most marked when the 
veins of the liver are closed, as in periphlebitis or Chiari's endophlebitis. 

( 1 ) The post-mortem appearances of active congestion are not char- 
acteristic. The liver is swollen, dark in color, and full of blood; the 
hyperemia is not limited to any one portion of the liver substance. 

(2) In passive congestion the liver is large in size, smooth or slightly 
granular in outline, and of a distinctly mottled hue. The surface of 
section presents the characteristic nutmeg appearance (the centre of the 
lobule being deeper), due to a marked congestion occurring in the 
central veins, the congested tissues being of a reddish-brown color. 
This is surrounded by a large area of a pale-yellowish color (fatty 
infiltration), with a third zone of cellular infiltration and new con- 
nective tissue. In rare cases this order is reversed, the congested area 
occurring at the periphery of the lobe and the lighter or fatty parts 
towards the centre. In chronic and well-marked cases there may be 
considerable induration and shrinkage of the liver substance, with 
irregular surface, so that the hypertrophy gives place to an atrophy, 
called cyanotic atrophy or Virchow's red atrophy. 

Emphysema. — Portions of the liver when squeezed under water 
show the escape of bubbles. This condition may be due to putrefaction 
or to the growth of gas-forming organisms during life. 

Fatty Changes.— (a) Middle life, (b) Alcohol, (c) Seden- 
tary habits, (d) Infectious fevers, (e) Certain poisons. (/) Ca- 
chexias, (g) Interference with local or general circulation. Classifi- 
cation. — (a) Fatty degeneration, (&) Fatty infiltration. (1) The 
liver may be increased or diminished in size. The capsule may be 



1 62 POST-MORTEM EXAMINATIONS 

smooth or wrinkled. The consistence is usually somewhat decreased; 
the organ is paler than normal and somewhat mottled in appearance. 
Periphery of lobule is first involved. The surface of section is smooth, 
usually bloodless, and imparts a greasy stain to the knife. The general 
color is a dull gray or grayish yellow. (2) In fatty infiltration the 
liver is often markedly enlarged, normal in outline, smooth to the touch, 
and of a somewhat pale, excessively fatty color. Globules of fat may 
be readily expressed with a knife. Hyperemia may obscure the char- 
acteristic appearance. 

Hepatitis, Suppurative. — Abscess of the liver may be due to: 
(a) Traumatism. (b) Extension from neighboring organs, — e.g., 
the bowel and the pleura, (c) Pyaemia, (d) Amcebic dysentery. 
(e) Malignant emboli. (/) Diseases of veins, as periphlebitis, throm- 
bophlebitis, and thrombo-umbilicalis. (g) Stoppage of bile, as from 
gall-stone or dead ascarides. (h) Idiopathic tropical disorders. Clas- 
sification. — (a) Pyaemic hepatitis. (b) Portal pyaemia. (c) Pyo- 
septicaemia or multiple abscess, (d) Tropical or endemic hepatitis. 
(e) Suppurative cholangeitis. (1) In multiple abscess the change in 
the liver depends upon the number of the abscesses. If these be few, 
the liver walls may be comparatively little altered; if they are very 
many, the liver is apt to be enlarged, softened, and friable. The ab- 
scesses themselves appear as minute foci which are non-encapsulated, 
the centre containing a thick white, yellow, or greenish pus surrounded 
by a zone of congestion. The abscesses may number from five to ten, 
or many hundreds. These multiple abscesses frequently arise from 
pyaemic embolism of the portal vein or hepatic artery or vein, or they 
may result from a cholangeitis. They may be generally distributed or 
appear in clusters. If from a malignant endocarditis, they are usually 
situated under the capsule. (2) Large abscesses occur in two forms, — 
the large chronic encapsulated abscess surrounded by a pyogenic mem- 
brane and the tropical or amcebic abscess. (See Dysentery.) The 
large abscess is usually single; there may be two or more. The right 
lobe is usually affected. There is a distinct limiting membrane. The 
pus is usually of a greenish-yellow color and often of a disagreeable 
odor. The surrounding substances often show but few changes, except 
as the result of pressure. 

Sarcoma. — This may be primary (very rare) or secondary. The 
most frequent variety is the secondary melanosarcoma following sar- 
coma of the eye, of the skin, or of the penis. In these cases the liver 



DISEASES OF THE LIVER AND GALL-DUCTS ^3 

is greatly enlarged, weighing as much as fifteen pounds, and the sec- 
ondary nodules, which are of a black or slate color, are usually uni- 
formly distributed throughout the gland. In primary sarcoma of the 
liver there are but few nodules, and these reach a large size, measuring 
at times five or six inches in diameter. Metastases to other organs 
often occur, though other portions of the liver may escape. 

Other Tumors. — In addition to carcinomata and sarcomata, the 
liver is the seat of adenomata, adenocystomata, angiomata, fibromata, 
and aberrant adrenal tumors similar to those found in the kidney. The 
cavernous angiomata are usually small in size and, when found, are 
usually seen on the surface of the liver in elderly persons. They may 
be injected with colored material by means of any of the hepatic blood- 
vessels, and then form excellent microscopic specimens for future study. 



CHAPTER XV 

EXAMINATION OF THE SKULL AND BRAIN 

The body is placed in the supine position on the side of the table 
nearest the operator, the head, elevated by a block placed under the 
neck and occiput, projecting slightly beyond the end of the table. If 
the cadaver be in a coffin or box, it may be drawn to the upper end 
thereof, the head being raised and placed upon a board laid across the 
top, the back supported by a head-rest, a block of ice, or any convenient 
bundle of rags or paper. Of the various forms of support employed, 
the Cornell head-rest (Fig. 37) is peculiarly well adapted for holding 
the head steady. 

Note any anomaly in the size or shape of the head. ( See page 270. ) 
The scalp should be subjected to the same careful preliminary scrutiny 
for evidences of disease or injury, remote or recent, as the other parts 
of the body. It is then divided by an incision extending from one 
mastoid process to the other (Fig. 109), passing over the vertex when 
the hair is abundant and about midway between the vertex and the 
external occipital protuberance when it is thin. If the hair be long, 
it should be parted along the proposed line of incision, in order that 
as little of it as possible mayj)e cut (Fig. no). For the same reason 
and to guard against damage to the knife, the cutting edge of the 
scalpel or cartilage-knife should be directed from the skull when the 
scalp is being cut. When all the tissues overlying the skull have been 
separated by force, the scalp is reflected backward and forward; the 
calvarium may be exposed from the occiput to or slightly beyond 
the frontal eminences. The eyes and nose should be protected by 
pledgets of cotton placed beneath the anterior flap. Care should be 
taken to avoid tearing the scalp at the extremities of the incision behind 
the ears, especially if the posterior incision with a large anterior flap 
be made. Indeed, it is for this reason that the incision should begin 
and end behind and not in front of the ears, for a tear behind the ear 
would hardly be noticed, while one in front would cause considerable 
disfigurement. The scalp may be so adherent to the cranium as to 
necessitate its removal by dissection with the knife or scraping with 
a chisel. Whatever instrument is used, guard against its slipping, lest 
164 




Fig. 109. — While the right ear is held back with the left hand an incision is started directly over the 
mastoid process. The remainder of the incision over the vertex will be made from within outward, thus 
avoiding dulling the knife and cutting the hair. 




Fig. 1 10.— After the initial incision behind the ear. the hair is parted when it is long, so as not to injure it. 




Fig. hi. — Method of sawing the skullcap. The temporal muscle has been cut through with a knife in the 
direction of the future sawing, and a pencil mark shows the posterior line along which to saw. The hand is pro- 
tected with a towel. 




Fig. 112. — Angular method of removing the brain. The saw markings in each case pass close to the ear and meet an 
inch or so above it. The left hand is covered with a towel to protect it from injury. 




Fig. 113. — Method of breaking 



up the inner table with an old knife after sawing, 
chisels made especially for this purpose.) 



(There are also various forms of 




Fig. 114. — Method of drawing off the skullcap with a retractor after the sawing is completed. 




Fig. 115.-Appearar.ee of the dura mater after removal of the calvarium, showing the superior longitudinal 

sinus and the meningeal vessels. 



EXAMINATION OF THE SKULL AND BRAIN 



165 



injury be done to the operator or to the subject. Avoid undue traction 
of the scalp, which would cause it to present a baggy appearance when 
replaced. 

The skull should next be examined in detail. Fractures and other 
evidences of injury may now be revealed which could scarcely have 
been discovered in the preliminary examination. Note should be made 
of the presence of atrophy, hypertrophy, or softening of the bone, of 
premature or delayed synosteosis and supernumerary bones, of tumors, 
syphilitic or tuberculous abrasions or openings, marks of previous 
trephining, of asymmetry and abnormal coloration, the " greenish- 
yellow" discoloration due to osteomyelitis or the " citron-yellow" due 
to tertiary syphilitic lesions, etc. (For cranial measurements and 
pathological types of skull see page 270.) 

There are two methods of removing the calvarium, — the angular, 
in which the skullcap is sawed in two intersecting planes meeting 
behind the ear, and the circular, in which the bone is divided in a single 
plane. The former method is usually to be preferred, as it permits 
more secure reposition of the skullcap, but the latter is easier of appli- 
cation and will, therefore, be considered first. 

The Circular Method. — The path of the saw, which may be 
marked with a pencil or the point of a knife, traverses a plane cutting 
the skull from half an inch to an inch above the glabella anteriorly, 
an inch or an inch and a half above the external auditory meatus 
laterally, and passing just above the inion posteriorly. This line will 
cross the temporal muscles obliquely, and they and their fascia should 
be divided with a knife instead of the saw, in order that their edges 
may be accurately approximated for suturing when the skullcap is 
replaced. 

Sawing the skull is no easy task; it may be greatly facilitated by 
the employment of an electric or dental engine. For this part of the 
operation it is a decided advantage to be ambidextrous. While the 
sawing is being done with one hand, the head must be steadied with 
the other, placed either on the vertex or on the face and protected 
by a towel, for the saw is liable to slip, especially when first applied. 
The scalp, especially of a female, should be protected from " sawdust" 
by wrapping towels about it. Proffered assistance should be declined, 
because, while it is natural to look out for one's own fingers, it is 
impossible effectively to guard another's. The reason I often give 
for not accepting aid is that "I am reasonably supposed to know 



!66 POST-MORTEM EXAMINATIONS 

where my hand is, but not where yours may be." The saw may be 
carried entirely through the bone or, better, only to the inner table, 
this being divided with chisel and hammer. In no case, however, 
where it is suspected that the skull may have been fractured should 
the latter procedure be adopted, as the force of the blow required 
might be sufficient to split the bone. While a post-mortem fracture 
may be recognized by the absence of extravasated blood, the enlarge- 
ment of a pre-existing fracture is more difficult to differentiate. A 
receptacle should be placed beneath the head to catch the cerebro- 
spinal fluid and the blood that escape when the skullcap is removed 
and the meninges are opened, and care must be taken to prevent spat- 
tering. The calvarium is loosened by twisting a chisel or the sharp end 
of a hammer in the kerf, and removed with a blunt hook. If instead 
of an instrument the fingers be used for the purpose, they must be well 
protected, as they are liable to slip and be abraded by the sharp edges 
of the bone. Traction should be made steadily and not in jerks, lest 
from a sudden giving way the calvarium be damaged by falling on 
the floor or surrounding objects be soiled by being spattered with 
blood or other fluid. When, as is sometimes the case, the calvarium 
does not readily yield to traction applied in front, it may often be 
easily detached by inserting the hook posteriorly. If the dura be 
adherent, as not infrequently happens in cases of chronic alcoholism, 
old injuries, or sunstroke, it may be loosened with a blunt instrument, 
or it may be divided along its margin with a pair of blunt-pointed 
scissors or a curved, probe-pointed bistoury cutting from within out- 
ward, the falx cerebri being incised close to the corpus callosum. In 
children under seven years of age this must always be done, as up to 
this time of life the dura is normally adherent to the osseous structures 
of the skull. 

The Angular Method. — In this method the skull is sawed in 
two planes which by their intersection form an obtuse angle at a point 
a little below and slightly posterior to the apex of the ear. Always 
try to saw above the line of the hair in front. Although this makes 
the anterior fossa deeper and consequently the removal of the brain 
more difficult, it obviates the ugly ridge on the brow so liable to be 
made by the inexperienced. It is necessary too that the angles be well 
sawed through and carefully broken, because if spicules of bone remain 
the brain may be caught and injured during its removal. (For this 
method of opening see Figs, in to 114 inclusive.) 



EXAMINATION OF THE SKULL AND BRAIN ^7 



In the French method of opening the adult skull with a hammer, 1 
the anterior and posterior flaps are made in the usual manner. A line 
one centimetre above the soft tissue is drawn around the skull, the 
temporal muscles being cut through with a knife; by means of blows 
with the hammer the skull is then fractured along this line. This 
method is much employed in France and in the hands of experienced 
operators gives good results. It must not be used in children, in cases 
of fractures, bone lesions, etc. The dura is opened along the circular 
incision, or, more frequently, crucial incisions are made on either side 
of the longitudinal sinus and each side is incised by a perpendicular 
cut running from the vertex down to the upper margin of the bone. 
The four pieces are then turned clown and the falx cerebri is cut ante- 
riorly just behind the crista galli and pulled backward. 

The thickness of the skull is next noted. It varies much, being 
usually greater in negroes and, at times, in syphilitic subjects. It 
also varies in different parts of the same skull, being thinnest in the 
temporal region and thickest at the occiput, and is often unequal in 
corresponding points of the opposite sides. Thin spots are readily 
detected by holding the calvarium to the light. The diploe may be 
entirely absent in some places, in which case the bone-dust will lack 
the reddish color commonly observed in recently sawed bone. The 
skull is usually from two to six millimetres thick. In rare cases the 
frontal sinus may extend high up and be of unusual thickness ; in one 
of my subjects it measured half an inch across at the top after removal 
of the calvarium in the usual manner. Note the relations of the 
external table, internal table, and diploe. Pay especial attention to 
the amount of blood in the latter; if abundant, suspect fracture. At 
times it is entirely bloodless. The skullcap should be held up to the 
light so that any inequality in its thickness may be perceived. The 
Pacchionian granulations often give rise to small nodular depressions 
in the inner table, which are of course perfectly normal and should 
not be mistaken for pressure atrophy. They sometimes cause perfora- 
tion of the bone. 

The grooves of the middle meningeal artery must be looked for 
on each side. In one of my cases of acromegaly the inner table resem- 
bled worm-eaten wood; the bone was soft and pliable and offered no 
resistance to the saw. It is necessary to be familiar with the normal 

1 J. Dejerine, Anatomie des centres nerveux, 1895. 



X 68 POST-MORTEM EXAMINATIONS 

yellowish-gray color of the inner table in order that changes in it may 
be readily detected. Whenever blood is found between the inner table 
and the dura, careful search must be made not only in its vicinity 
but also on the opposite side for a fracture by contrecoup. In the exam • 
ination of the dura mater note its thickness, the degree of distention, 
its color, which is normally gray and never very red, and the amount of 
blood contained within it. As all liquid naturally gravitates down- 
ward, those portions of the dura which cover the most dependent parts 
will be most distended, unless, as often happens, an injury of this mem- 
brane has allowed the fluid to escape. 

The arteries lie between the two veins. The larger arteries usually 
contain more blood than the veins. The dura is supplied with but 
few capillaries and these rarely become inflamed. 

In the examination of the outer surface of the dura mater (Fig. 
115) note alterations in color and gloss. The latter is often lost in 
consequence of tumors, hemorrhage, hydrops, abscess, and other con- 
ditions that cause increase of intracranial pressure. Search for hemor- 
rhages (which at times are profuse and depress the brain) and their 
points of origin, Pacchionian bodies (which must not be mistaken for 
tubercles), bulging tumors, and external pachymeningitis (ossified, 
purulent, syphilitic, or tuberculous), etc. The degree of tension due 
to fluid, etc., may be determined by puncture or by pinching up the 
dura. 

The brain may be exposed, but not dissected, before the heart is 
incised, as the quantity of blood in the cerebrum may be modified by 
venous oozing during the examination of the thorax. If the brain 
is to be injected, it is best not to remove the dura, as by its detachment 
usually some of the veins entering the longitudinal sinus are torn, and 
this permits the escape of the injecting fluid when under pressure. It 
has been shown that this operation can be performed without external 
disfigurement while the brain is in situ by forcing the fluid through a 
cannula introduced by way of the nostrils or the orbits. 

The longitudinal sinus is opened throughout its entire length with 
a pair of probe-pointed scissors, and the condition and quantity of the 
contained blood are noted. 

The dura is divided parallel with and slightly above the sawed edge 
of the skull, with a pair of blunt-pointed scissors, which may be intro- 
duced through a chance nick made by the saw or through an opening 
made with a knife for the purpose. The incision is carried completely 



EXAMINATION OF THE SKULL AND BRAIN 



169 



around the skull except at the poles of its anteroposterior diameter, 
where it is necessary to sever the falx cerebri. The arachnoid surface 
of the two lateral flaps of the dura may be examined by reflecting them 
to one side. The character of the blood in the membranes of the 
brain and in its cortex, the fluid in the subarachnoid space, the charac- 
ter of the sulci and convolutions, and the presence of lymph are all to 
be noted. 

To detach the falx grasp both folds of the frontal dura with the 
left hand, and with the right insinuate the blade of a knife along the 
outer face of the left fold of the dura to its attachment to the ethmoid 
bone. This is severed by turning the cutting edge of the blade inward 
towards the falx and detaching it along the line of its insertion from 
before backward, as near the crista galli as possible without injury 
to the olfactory bulbs. As the knife reaches to the anterior genu of the 
corpus callosum, the index-finger may be gently introduced into the 
longitudinal fissure so that a view may be had of the portion to be cut. 
It is no unusual thing to leave behind a thin strip of the dura just 
above the corpus callosum, which mistake may cause annoyance to the 
operator or injury to the brain during its removal. 

The dura may now be drawn backward and cut off posteriorly or 
left in situ (Fig. 116). The portion of the pia mater dipping down to 
the genu and splenium of the corpus callosum may be detached with 
forceps, and that overlying the surface of the cerebrum with the fingers. 
The handling of this delicate membrane can be greatly facilitated by 
allowing a stream of water to flow gently over it .during its removal. 
The pia is colorless when normal, but may be gray or grayish Avhite 
when thickened, yellow when pus is present, or red from hyperemia 
or hemorrhage. 

The anterior extremities of the frontal lobes are gently raised with 
the tips of the fingers of the left hand, and any remaining shreds of 
dura are severed to prevent injury to the cerebral tissue in the frontal 
region or corpus callosum. With the handle of a scalpel the olfactory 
bulbs are now shelled from the grooves in the cribriform plate of the 
ethmoid bone in which they lie, and the entire brain is gently turned 
outward while supported by the left hand. The various nerves and 
vessels are then divided, as near as possible to their respective foramina, 
with a sharp, narrow-pointed scalpel, always cutting towards the bone. 
First the ophthalmic artery and optic nerve are severed close to the 
optic foramen. Then the dura enclosing the pituitary body is cut 



I jo POST-MORTEM EXAMINATIONS 

with a sharp knife near to the bone (sella turcica) at all points except 
posteriorly near the infundibulum, great care being taken not to injure 
the delicate hypophysis, which then may be shelled out and the remain- 
ing portion of the dura behind be excised with scissors. The internal 
carotids are cut long, especially if the brain is to be injected. As the 
temporosphenoidal lobe leaves the middle fossa of the skull, the ten- 
torium cerebelli is divided with blunt-pointed scissors, or a knife with 
a broad flat back made especially for this purpose, along the superior 
border of the petrous portion of the temporal bone, preferably passing 
from the median line towards the sides. In making this incision care 
must be taken not to injure the cerebellum. 

The brain mass being now supported on the left hand, cut the cord 
as low down as possible by a transverse incision. Pick's myelotome 
is a very convenient instrument for this purpose. Orth thrusts the knife 
through the centre of the cord and severs first one side and then the 
other. Any attachments of the spinal cord and medulla can readily 
be loosened by introducing the forefinger into the cavity of the spinal 
column and through the foramen magnum. Of course, if the cord 
has already been removed, it remains only to cut the vertebral vessels. 

The brain is now entirely free, but the cerebellum still remains in 
the posterior fossa, from which it is best removed by holding it firmly 
to the cerebrum with the fingers of the right hand and turning the 
brain first to one side and then to the other (Fig. 117). A towel pre- 
viously rolled up into the form of a turban makes an excellent tempo- 
rary resting-place for the inverted brain. 

During this entire procedure, which has taken longer to describe 
than it does to perform, the secant has been searching the exposed parts 
for any lesions or abnormalities, as their presence may modify subse- 
quent processes. 

Examine the external surface of the brain, the adherence of the 
pia-arachnoid being tested in several places, not forgetting the fourth 
ventricle, the circle of Willis, and the course of the middle cerebral 
artery lying in the fissure of Sylvius. With the latter the island of 
Reil and the retroinsular convolutions are also exposed. 

INTERNAL EXAMINATION OF THE BRAIN. 

The brain may be sectioned either immediately upon its removal or 
after first being hardened, each method having its advantages. If an 
immediate diagnosis is required or colleagues are present to give 



EXAMINATION OF THE SKULL AND BRAIN 



I 7 I 



unusual interest to a discussion of the findings, the sectioning will 
probably be done at once. If any hemorrhagic lesion is suspected, 
it is more conspicuous in the recent state, and a wholly unexpected 
bacteriological investigation might be demanded by the revelations of 
the incisions. If none of these considerations prevail, the brain is 
hardened in a medium which will not interfere with any microscopical 
work that may be desired after the sectioning. Since hardening in 
certain fluids is necessary for certain stains and entirely precludes 
others, we must first of all decide what staining methods will be used 
before a choice of hardening fluids can be made. A two and one-half 
per cent, solution of bichromate of potassium or Miiller's fluid will 
develop color contrasts between the white and gray matter and furnish 
material for Weigert and Golgi work, but the later methods for gan- 
glion cells and neuroglia are precluded. Formalin is suitable for all 
special staining methods, including Nissl's, though the best results 
are obtained when the tissues are hardened in alcohol. 

The brain may be hardened entire in a ten per cent, solution of 
formalin in a week or ten days and be suited for general topographical 
work. For finer histological methods the parts should be serially 
incised, the sections being not more than three millimetres thick and 
remaining in situ, or, if the material to be studied is not superficial, 
the brain may be incised according to the methods herein to be given 
and then hardened. The advantages of hardening the brain in most 
pathological cases are so obvious that they do not require mention. 
It should always be done unless contraindicated, and when the fresh 
brain is sectioned and examined, the incisions should be so made that 
all the segments will fold together like the leaves of a book, — unin- 
jured, undisturbed in their structural relationship, and fit for the most 
exhaustive microscopical examination. 

Whether the brain is sectioned first or after hardening, the choice 
of a method will be somewhat determined by the situation of the 
lesion and the desire to preserve intact all its structural relations. 
Morbid changes in the cortex which we might wish to trace down 
through the internal capsule would be studied only with the greatest 
difficulty after sectioning by Meynert's method, whereas if the lesions 
were bulbar or situated anywhere in the brain-axis this method would 
be very advantageous, since it permits of examining the whole of the 
brain-axis by serial sections. 

The centrum ovale is well studied by Pitres's method, but future 



172 POST-MORTEM EXAMINATIONS 

microscopical investigation is impossible. The same is true of Noth- 
nagel's method, and to examine lesions of the internal capsule we must 
have horizontal sections. For exposing suspected or unsuspected 
lesions, for gaining a good idea of the general condition of the brain, 
and for ease and rapidity of routine work, probably no method is more 
useful than that of Virchow. Unfortunately, it does not favor micro- 
scopical examination and therefore is rather sweepingly condemned 
by some authors. 

Dejerine makes a special effort so to section the brain that it may 
be sufficiently exposed without in any way interfering with future 
investigation. 

Virchow' s Method. — A long, sharp knife should be used in the 
dissection, which should be kept clean and moist by frequent washing, 
so that the cut surfaces will be even and smooth. A dull knife tears the 
brain substance more or less, thus distorting the delicate structures. 
Virchow insisted strongly upon the necessity of a long, clean, smooth 
incision being made at one stroke, and said that he would rather have 
a wrong incision rightly made than a right incision wrongly per- 
formed. 

The brain is placed on its base with its occipital lobe towards the 
operator. Laying the left hand upon the left hemisphere, with the 
thumb in the longitudinal fissure and the fingers upon the convexity, 
raise this hemisphere slightly and pull it away from the median line 
so as to expose the corpus callosum. Insert the point of a thin nar- 
row knife into the roof of the lateral ventricle, which lies immediately 
below the corpus callosum, well forward and two or three millimetres 
externally to the median raphe of the corpus callosum (Fig. 118). 
Make a concave incision — concavity directed outward — through the 
roof back to the posterior cornu, being careful not to injure the floor 
of the lateral ventricle. Note the character and quantity of fluid 
present, which normally is perfectly clear and about three cubic centi- 
metres in amount. Connect the two extremities of the first incision by 
a second and third incision meeting at an angle of 45 degrees just 
outside the basal ganglia. In this manner the greater portion of 
the cerebral cortex on the left side will be removed away from the 
basal ganglia for future sectioning (Fig. 119). The right hemisphere 
may be turned half around and sectioned in the same way. 

The knife is then introduced into the foramen of Monro and the 
anterior fornix is brought forward, exposing the vela interposita and 




Fig. 116. — Appearance of the brain after removal of the dura, which has been left attached to its posterior 

extremity. 



Fig. 117. — Method of removing the brain after it is severed from the body. 




Fig. 118. — Dissection of the brain; commencement of initial incision. 




Fig. 119. — End of initial incision. 





Fig. 121. — Central portion of the brain with the cerebellum, pons Varolii, and medulla 
oblongata still attached. 



EXAMINATION OF THE SKULL AND BRAIN 



173 



the choroid plexuses, which with the body of the fornix are carried 
back, thus exposing the third ventricle (Fig. 120). Then examine the 
corpus fimbriatum, the lyra, the anterior, posterior, and middle com- 
missures, the corpora quadrigemina, the pineal body, and the com- 
mencement and lumen of the iter a tertio ad quartum ventriculum. 
If it be desired to examine the fifth ventricle, an incision is made 
directly in the median line into the septum lucidum, parallel to the 
corpus callosum, the anterior fornix being elevated by the left hand 
and thus put on a stretch. 

The crura are then severed by transverse incisions joining at about 
a right angle in the median line. The cerebellum, the medulla oblon- 
gata, and the pons Varolii are next to be removed. After examining 
for dilated veins, tumors, and cysticerci, transverse incisions are made 
in the cerebellum on one side through the centre of the arbor vita?, and 
then on the other side. The cerebellum may, however, be removed 
before these incisions are made by severing the medulla oblongata and 
the pons Varolii, and dividing the cerebellar hemispheres in the median 
line into two parts. The pons, the medulla, and the commencement of 
the spinal cord may now be cut transversely, by incisions one-fourth 
to three-eighths of an inch apart, and all pathological changes carefully 
noted, but these portions are preferably hardened previous to exami- 
nation, which is best accomplished by the preparation of serial sections. 
(Figs. 121 to 126 inclusive.) 

Both Nauwerck and Orth, before making transverse sections of 
the pons and medulla, fold the sections of the brain together as you 
would the pages of a book in order that it may be turned. Then, 
pushing the fingers of the left hand under the pons and medulla, the, 
transverse cuts may be made. In case of tumors or metastatic condi- 
tions simpler methods may be used; thus, only one longitudinal or 
one transverse section may be made through the diseased as well as 
the healthy tissue, while the arachnoid is left intact. 

Meynert's Method, slightly modified by Blackburn. — The 
brain is placed with its base upward and the cerebellar end towards 
the operator! The cerebellum is elevated and the pia mater cut through 
above the corpora quadrigemina, around the crura, and along the 
inner margins of the temporal lobes until the middle cerebral arteries 
are reached. The Sylvian fissures are opened to their entire extent, 
the opercula are raised, and the insular lobes exposed to their limiting 
furrows. 



174 



POST-MORTEM EXAMINATIONS 



The apices of the temporal lobes are now elevated, and, with the 
knife held nearly horizontal, their junction with the base is cut through 
until the anterior extremities of the descending" cornua are opened. 
The knife is inserted in the descending horn, and the incision is carried 
backward as far as the posterior angle of the insula, or even some 
distance beyond it, severing some of the convolutions at the posterior 
extremity of the Sylvian fissure. 

The next incision is made to separate the basal piece from the 
posterior extremities of the frontal lobes. It connects the anterior 




Fig. 127. — Basal ganglia, with cerebellum, pons Varolii, and medulla oblongata attached, in Meynert's 
method of dissecting the brain. The twelve cranial nerves are shown. C, cerebellum ; F, flocculus ; Af, 
medulla; P. V. , pons Varolii ; T.L., temporal lobe ; F. L ., frontal lobe; P, peduncles; C.a., corpora 
albicantes ; C.c, central commissura ; R. J. C, retroinsular convolution ; O. C, optic commissura ; P.S., 
posterior roots of olfactory ; /, insula. (After Dejerine.) 

boundaries of the islands and opens the anterior horns of the ven- 
tricles. The incision may be a slightly curved, transverse one, con- 
necting the anterior border of the islands; or, by a little care and a 
double crescentic cut, the exact boundaries of the convolutions may be 
followed. 

The cerebellum is now raised, the knife entered at the posterior 
angle of the island, and the incision carried along the outer limiting 
furrow until it meets the cut previously made through the anterior 
border. Care must be taken to keep the knife in the angle between the 



< 5. 
n C 
a- Ji 



S St 
l-l < 



o >o 





Fig. 123.— Method of removing the cerebellar lobes from the pons Varolii and the 
medulla oblongata. 




Fig. 124. — Method of sectioning the cerebellum. 




Fig. 125.— The whole brain after it has been sectioned. 




Descending fornix 



Descending fornix 



Fig. 126. — Section of the brain. The lines and arrows show the position and direction of the various 

incisions. (After Nauwerck.) 




Fig. 128. — Sectioning of the brain. A £, incision practised by Flechsig ; C JD, that' of Brissaud ; E F y 

that of Dejerine. (After Dejerine.) 




Fig. 129. — Incisions made by Dejerine in a case of cortical'lesion previous to^hardening. 

(After Dejerine.) 



EXAMINATION OF THE SKULL AND BRAIN ^5 

roof of the ventricle and the basal ganglia, to avoid injuring the latter. 
The basal piece is now lifted until the anterior crura of the fornix and 
the septum lucidum may be severed, and the basal section thereby 
completed. 

The basal piece thus separated includes the island of Reil, the basal 
ganglia, the crura, pons, medulla, and cerebellum. (Fig. 127.) 

Pitres's Method. — The lateral ventricles are exposed as in Vir- 
chow's method. The hemisphere lies on its internal surface and a 
series of transverse vertical sections are made parallel to the fissure of 
Rolando. Pitres's method is very useful for localizing lesions in the 
centrum ovale, but not at all adapted to studying the internal capsule 
nor for subsequent microscopical work. The same is true of the closely 
similar method of Nothnagel. 

Some operators do not even take the trouble to remove the brain 
from the skull, but merely make a number of transverse incisions across 
the cerebral structures. This method is only mentioned to be con- 
demned, though it may diagnose a hemorrhage, a tumor, or an abscess. 
The next method to be described, that of Dejerine, gives the best 
results of any of the methods now in vogue. 

Method of Dejerine. 1 — The brain is examined upon all its sur- 
faces to see if there be any cortical lesion. The inferior surfaces of the 
crura are carefully inspected for secondary degenerations. The cere- 
brum is separated from the cerebellum by sectioning the pons hori- 
zontally in a plane directly parallel with the inferior surface of the 
hemispheres and passing just above the great root of the trifacial. Fig. 
128 shows the direction of the incisions adopted for this purpose by 
Flechsig, Brissaud, and Dejerine. This divides the brain into two 
portions. The upper one contains the two hemispheres, the cerebral 
peduncles, and the superior portion of the pons, while the corpora 
quadrigemina is preserved intact by the obliquity of the incision. The 
lower portion contains the rest of the pons, the cerebellum, and the 
medulla. The surfaces of the section through the pons are carefully 
examined for degenerations in the pyramidal tracts, and the two hemi- 
spheres are separated after determining in which one the lesion is situ- 
ated, which is often decided by the appearance of degenerations in the 
cut surfaces of the pons. While Dejerine regards this as important to 
determine, because the corpus callosum should be sectioned as closely 

1 Anatomic des centres ncrveux, pp. 22 et seq. 



1 76 POST-MORTEM EXAMINATIONS 

as possible to the normal hemispheres, and the incision should not pass 
through the interpeduncular space but encroach at least a centimetre 
upon the sound peduncle and corresponding portion of the pons, other 
neuropathologists object to this mode of procedure as being apt to cause 
disfigurement of the parts. 

The method of examining the hemispheres is determined by the 
situation of the lesion, — whether it is central or cortical. If central 
the only degenerations that are of importance are those of the tracts 
of the internal capsule and in the region of the tegmentum (dorsal 
portion of the crus cerebri). Divide each hemisphere by a horizontal 
incision passing through the superior third of the optic thalamus, 
harden, prepare a drawing of the part, and section with a microtome. 

If the lesion is cortical the brain is sectioned by ( i ) a vertical 
transverse incision (Fig. 129, CD) passing just posterior to the sple- 
nium of the corpus callosum, and (2) a vertical transverse incision 
(A B) just anterior to the knee of the corpus callosum. In this way 
the hemisphere is divided into three segments. The posterior segment 
is composed of the occipital lobe and part of the parietal. The anterior 
is the forepart of the frontal lobe. The central is the largest and con- 
tains the regions adjacent to the fissure of Rolando, the middle portion 
of the temporal convolutions, the posterior portion of the frontal con- 
volutions, the basal ganglia, the cerebral peduncle, and the correspond- 
ing part of the pons. The anterior and posterior segments are hardened 
as they are, and the central segment also if the cortical lesion is exten- 
sive and deep so that the fluid can penetrate easily ; if not, a horizontal 
section (E F) is made through the superior third of the optic thalamus. 
In either event the pieces are hardened and cut with a microtome, pre- 
ferably of the Gudden type. The anterior and posterior segments are 
cut vertically transverse and numbered. The central segment or seg- 
ments are incised horizontally. In this way a cortical lesion can be 
localized with great precision not only, but traces of degenerating fibres 
may be studied throughout their whole extent, which is not practicable 
by any other method. 

Hamilton's Method. — Hamilton injects the vessels of the brain 1 
as follows : The brain is freed from the dura, but not from the pia 
and arachnoid, weighed, and injected through the vessels at the base 
with Miiller's fluid or any other hardening fluid desired. It is well to 

1 Text-book of Pathology, 1889, vol, i. p. 56. 



EXAMINATION OF THE SKULL AND BRAIN 



177 



have a round stoneware jar with a lid of sufficient size, three fair-sized 
cannulas, several feet of good rubber tubing of a caliber to receive the 
ends of the cannulas, and a three-tubed " distributer." A piece of the 
rubber tubing about eighteen inches long having been firmly tied on 
one end of a cannula, its other end is tied into an artery, — viz., one 
into each carotid and one into one of the vertebrals, the opposite ver- 
tebral being securely ligated. The brain, with its attached tubes, is 
now placed in the jar, which is partly filled with the hardening fluid. 
The weight of the cannulas and tubes is taken off the vessels by sus- 
pending the tubes over the edge of the jar. Tie the other ends of the 
rubber tubes to the three arms of the distributer, and connect the com- 
mon tube with the stopcock of a tank filled with the preservative fluid, 
which can be conveniently raised or lowered at will, and is now placed 
about four feet above the brain in the jar. 

When certain that all attachments are secure, the stopcock is grad- 
ually opened, allowing the tubes to become filled and the fluid to per- 
colate slowly through the brain. Care should be taken that the can- 
nulas do not bend the arteries short upon themselves, thus occluding 
their lumina. The first fluid which passes through will be mixed with 
blood and should not be used again, but when it has become clear 
it may be used over and over. It usually runs through very quickly, 
and the tank should be refilled at least every day for the first week, 
and oftener if convenient. The brain should always be in an excess 
of the fluid and a vessel provided for the overflow. For refilling the 
tank it is best to draw some of the liquid out of the jar w T ith a siphon, 
which will not disturb the brain or the position of the cannulas. 

A week or two will suffice in urgent cases, but the longer the brain 
remains in the fluid the better will be the hardening. Some of my 
most beautiful specimens are those which were kept in Miiller's fluid 
for five or six months. Haste and thoroughness are incompatible in 
this process. No padding should be used to keep the organ in position, 
the best and surest agent for this purpose being a plentiful excess of the 
liquid and an occasional change in its position. 

If it seems unnecessary to inject the vessels, the following method 
may more easily be carried out and gives most excellent results. An 
open jar, bucket, or wash-basin is one-quarter filled w T ith absorbent 
cotton, and Miiller's fluid — to which one per cent, of formalin may be 
added with great benefit — is poured in until the vessel is about half full. 
The brain, after being weighed, is carefully placed in the centre of 



!^8 POST-MORTEM EXAMINATIONS 

the vessel and more fluid is added until the organ is well covered, 
when it is placed in a refrigerator. If this be done, even though the 
arteries have not been injected nor any incision made into the ven- 
tricles, there is no danger that the brain will decompose, even in sum- 
mer. On the next day the position of the brain is altered and the fluid 
changed. The renewal of the fluid can best be accomplished with a 
siphon, only a part of it being removed at one time. 

The fluid is changed again on the third day, then every other day 
for three times, twice a week for the next three weeks, and once a 
week for the final three weeks. Remember that the jar is uncovered, 
and this allows of the evaporation of the fluid and possible spoiling 
of the specimen. The brain can then be thoroughly washed and put in 
80 per cent, alcohol, or the Mullers fluid can after the fifth or sixth 
week be diluted with one-fifth alcohol, then with one-quarter, one- 
third, one-half, and finally three-quarters alcohol, where the brain can 
be kept for several months until it is transferred to the alcohol of 80 
per cent, strength. Instead of Muller's fluid a 2.5 per cent, solution of 
bichromate of potassium may be employed. It is important to remem- 
ber that nervous tissue preserved for the purpose of study by the Nissl 
method should not be placed in Muller's fluid, but in alcohol or for- 
malin. About two thousand cubic centimetres of a 10 per cent, forma- 
lin solution are used and changed every third day. The solution must 
be kept in a tightly closed jar. 

Giacomini's Method. — This is well adapted for the macroscopical 
study of the brain, but, on account of the zinc chlorid used, the tissue 
is rendered unfit for microscopical work. If the specimen is a brain 
tumor, a small portion of it may be placed in a hardening fluid for 
microscopic study and the remainder then treated by this process. 

The brain, in as fresh a state as possible, is put into the Liquor 
zinci chloridi (U. S. P.). It will be found to float at first and should 
be turned several times the first day. On the second day the pia and 
arachnoid, which until now have been useful in keeping the brain 
intact, are removed while the organ is under water or floating in the 
fluid; if allowed to remain longer, they become so adherent to the 
cortex as to be separated with difficulty and more or less damage to 
the cortical substance. The brain is left in the fluid for from six to 
ten days, then removed, well washed with water, and put in 95 per 
cent, alcohol for ten days or two weeks and next in glycerin for another 
ten days or more. After this it is placed in absorbent cotton and 



EXAMINATION OF THE SKULL AND BRAIN iyg 

exposed to the air in a dark place free from dust. Any exudation 
should be carefully removed, and when no more appears (which may 
be in from several weeks to as many months) the surface is to be 
well coated with the best mastic varnish applied with a soft camel's- 
hair brush. To prevent flattening of the surface upon which it rests, 
it must be well packed in absorbent cotton and its position frequently 
changed. 

Kaiserling Method. — See page 261 for the preparation of brains 
with the object of preserving their natural coloration. 

In the coroner's work it is often necessary to make a diagnosis 
between heart-disease and apoplexy, when, because of baldness of the 
individual or for lack of time, it is impracticable to open the head. In 
such cases I have found it feasible to trephine just above the ear and 
from this point tap the ventricles and other situations liable to be the 
seat of hemorrhage, using an instrument resembling an apple-corer to 
remove brain substance for examination, though enough clotted blood 
may be brought out attached to a long thin brain-knife passed into 
the places where hemorrhage usually occurs — i.e., the ventricles and 
the cerebellar lobes — for the purpose of establishing a diagnosis. 

The base of the skull and its sinuses are next to be examined. 
Study the dura at its base for ( 1 ) inflammation resulting from frac- 
ture or caries, (2) tubercles, (3) gummata, (4) thrombosis of lateral 
sinus, (5) pachymeningitis and leptomeningitis, and (6) tumors. A 
fracture may be hid by the dura, but its situation will usually be 
shown by the presence of hemorrhage. The dura must be stripped oft, 
though this often consumes considerable time, so that the surface of 
the bone may be exposed. Unless this is done, a linear fracture — one 
near the foramen magnum, for example — might readily be overlooked. 
Special examinations should now be made of the orbit, internal ear, 
and nasopharyngeal cavities. 



CHAPTER XVI 



THE SPINAL CANAL AND CORD 



The spinal cord may be removed either anteriorly or posteriorly, — 
i.e., by excising the bodies of the vertebrae through the thorax and 
abdomen freed from their viscera or by severing the laminae and spinous 
processes of the vertebrae through an incision posteriorly. The latter 
route is decidedly the more convenient and is used whenever possible. 
Generally it is best to remove the cord before the abdomen is opened, 
this being a much cleaner operation, an important factor in private 
practice. 

The cadaver is placed prone upon the table, with the head hanging 
over the end or, better, with a block under the chest and neck and, if 
desired, one under the lumbar region. Beginning at the external occipi- 
tal protuberance, an incision is carried along the spinous processes to 
about the fourth lumbar vertebra, dividing all the tissues down to the 
bone. (Figs. 130, A B, and 131.) The superficial and deep structures 
are then dissected from the bones, exposing the vertebral groove on 
either side of the spinous processes. Or, after incising the skin over the 
spinous processes, insert the knife, with its back down, at the lower 
end of the incision and cut upward along the column, keeping the blade 
pressed against the spinous processes. In this way the fibrous attach- 
ments are cut close and the vertebral groove is clean and free from 
troublesome soft tissues. The soft parts should be very thoroughly 
removed, as they would interfere considerably with the subsequent 
sawing. This can be quite well done by scraping with a chisel or an 
old knife. 

In cases of luxation, fracture, Pott's disease, etc., it may be 
desirable to remove portions of the vertebral column en masse. This 
can readily be done by the proper use of a saw after severing the inter- 
vertebral cartilages above and below the lesion. The space is then 
filled by inserting a stick and pouring plaster upon it. 

The canal is easily opened with Luer's rhachiotome, an adjustable, 
double-bladed saw devised for the purpose ( Fig. 21). It does the work 
more quickly, but has the serious fault that it is liable to become im- 
pacted and injure the cord in its release. The same object may be 
180 




Fig. 130. — Lines for removing the spinal cord and the brain through a 
small triangular occipital incision. A B, initial incision for removal of the 
cord ; CD. curved incision for the purpose of avoiding division of the skin 
above the dressed portion of the body ; E A F, angular incision in the 
occipital bone through which to remove the brain without elsewhere 
opening the skull. 




Fig. 131. — Position of the body in removal of the spinal cord. The primary incision is being made. 




Fig. 132. — Removal of spinal cord. The primary incision has been made and the vertebral column freed 
from muscle, fascia, etc. The angle at which the saw should be held is well shown. 



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THE SPINAL CANAL AND CORD l8l 

accomplished with a single-bladed saw having curved ends (Fig. 17). 
The lamina should be sawed close to the transverse process, with the 
saw teeth held away from the spine at an angle of about thirty degrees 
(Fig. 132). Unless this direction is taken there is some danger that 
the canal will be missed or that the blade may enter it and the cord 
be injured. Orth calls attention to the fact that one can tell when 
sufficient sawing has been done by the mobility of the spinous processes. 
Other instruments which may be used are the double chisel of Esquirol, 
the knife-shaped chisel of Brunetti, and the rhachiotome and hammer 
of Amussat, the latter being much preferred in France to Luer's rha- 
chiotome, which is not approved of. After the canal has been opened 
in the dorsal region with the saw, a pair of bone-nippers is used to pry 
up the portions of vertebra thus loosened, and the dura is exposed 
(Figs. 133, 134). The sawing can then be continued in both directions 
until the entire canal is opened, except the atlas and axis, which had 
better be cut with bone- forceps (Fig. 135). In using either bone- 
forceps or pliers be very careful not to produce artefacts of the cord. 
The cord at the first dorsal vertebra is then tied with a string, so as to 
have the situation accurately determined, or the first dorsal nerve may 
be dissected out and left attached to the cord. 

The spinal cord covered with its membranes may now be studied 
in situ, after which the dura and the spinal nerves are divided below the 
cauda equina. The dura being elevated with the fingers or forceps and 
pushed to one or the other side, the spinal nerves are cut, with a long, 
thin, narrow-pointed, sharp knife, close to their points of entrance into 
the intervertebral foramina. (Fig. 136.) The dura at the foramen 
magnum can best be severed from the bony margin above after the 
brain has been removed. The cord may be taken away with the brain 
attached if so desired. The spinal ganglia may be extracted with the 
nerves and cord by cutting away the articular processes and gently 
pulling the cord, by the dura, to the opposite side and severing the 
nerve as far in the foramen as possible. 

By making a median incision in the dura mater the cord is exposed, 
and can, of course, be removed. This procedure, however, is more 
liable to cause injury to. the cord than the method given above. 

After freeing all points of attachment the cord must be very gently 
transferred to the table or tray for further examination. Study the 
dura for ( 1 ) thickness, ( 2 ) color, ( 3 ) blood, the cerebrospinal fluid 
for (1) pus, (2) blood, and the pia for (1) expansion, (2) thick- 



1 82 POST-MORTEM EXAMINATIONS 

ness, (3) contained blood, and (4) color. Gentle palpation may 
reveal areas of softening or sclerosis. The further manipulation of the 
part will depend upon the extent of the examination required. If the 
cord is to be preserved for future study, the dura is opened in the 
median line throughout its entire extent, the blade being inserted at 
the lower end, and transverse incisions about one inch apart down to the 
pia are made in the cord. It may be hardened at the same time and in 
the same jar as the brain by curling it around that organ; but it is 
better to suspend it by the dura, with a small weight attached, in a long 
jar, or it may be kept in such a jar lying upon its side. In summer 
the jar should be placed in the refrigerator. 

If the examination is to be completed immediately, the cord is laid 
out on the table and the dura opened throughout its entire length as 
already directed. Note is made of the conditions observed. Much 
valuable information can be obtained by the macroscopic examination, 
especially if a hand-glass be used and diagrams made at the time. 
Then, with a sharp, thin knife, which should be moistened with water 
after each incision, transverse sections about an inch apart are made 
through the cord and membranes ; the under surface of the dura, how- 
ever, is left uncut, in order that the cord may be replaced in its entirety. 
Areas of softening should not be incised, because of the inevitable dis- 
turbance thus produced in the relations of component parts. 

Where the avoidance of disfigurement above the parts covered by 
clothing is a matter of great importance, sufficient room for opening 
the cervical canal can be obtained by making a crescentic incision from 
the centre of one shoulder to the other, with the concavity towards the 
head, and dissecting up the skin. (Fig. 130, CD.) 

Sometimes it is advantageous to open the canal by removing the 
vertebral bodies through the long anterior incision. Brunetti's chisels 
were devised for this purpose. After removal of the thoracic and ab- 
dominal viscera, the pointed guard is inserted in the vertebral canal, 
and the instrument, held parallel with the long axis of the spinal 
column, is driven forward with a mallet, thus severing the pedicles and 
removing the bodies or anterior wall. By this method the spinal 
ganglia are said to be rendered more easily accessible. The remaining 
steps are about the same as those described for the posterior incision. 



CHAPTER XVII 

DISEASES OF THE BRAIN AND CORD 

Abscess of the Brain. — There is a circumscribed collection of 
pus in or upon the brain substance, with or without a pyogenic mem- 
brane, (a) Micro-organisms, — e.g., Staphylococcus pyogenes, Strep- 
tococcus, the diplococci of pneumonia, gonorrhoea, and cerebrospinal 
fever, Bacillus coll communis, the bacillus of typhoid, influenza, etc. 

(b) Traumatism, (c) Extension of disease from the middle ear or 
mastoid cells and cranial bones, (d) Septic emboli from distant foci, 
— e.g., abscess of the liver, ulcerative endocarditis, putrid bronchitis, 
localized bone-disease, etc. (e) Actinomycosis and other mycotic 
germs (rare). Classification. — (a) Primary (rare) or secondary 
(common), (b) Single (from extension) or multiple (metastatic). 

(c) Large (size of a walnut or an orange) or minute (then usually 
multiple). Seats. — (a) Cerebrum, usually in the temporo-sphenoidal 
lobe (most common), (b) Cerebellum, especially in middle-ear dis- 
ease, (i) Acute abscesses, usually about blood-vessels; are minute, 
with no definite wall; contain pus mixed with reddish debris and 
softened brain matter. (2) Chronic abscesses, may be superficial or 
deep; have a pyogenic membrane, which develops in from three to 
five weeks; pus has a greenish tint, an acid reaction, and may have 
a peculiar odor depending on micro-organisms. It may undergo fatty 
degeneration, but cystic formation is doubtful. 

Acromegaly. — A chronic disease of nervous origin, occurring 
most frequently in adults, and characterized by an overgrowth of the 
bones, especially those of the face and extremities, by malnutrition, 
and by impairment of the senses. Morbid changes are always found in 
the pituitary body (hypertrophy, colloid degeneration, tumors, etc.) 
and usually in the thyroid and thymus glands. There are marked 
hypertrophy of the bones of the face (especially the maxillae) and 
osteophytic growths on the bones of the hands and feet, with exag- 
geration of the normal ridges and tubercles. The thorax is enlarged 
and kyphosis may be present. The sternum is thickened, lengthened, 
and widened, as are also the ribs and clavicles. There may be hyper- 
trophy of the pharynx and larynx, leading to marked dyspnoea. In 

183 



184 POST-MORTEM EXAMINATIONS 

one of my cases there was found after death a sarcoma of the pituitary 
body; in another, all of the glands of the body appeared to be hyper- 
trophied. I have removed post mortem the pituitary body through 
the orbit. Under acromegaly may also be classed osteitis deformans, 
an affection which causes softening and distortion of the long bones 
of the body; hypertrophic pulmonary osteo-arthropathy, where 
there is antecedent lung disease and the bones of the skull are not 
involved, and leontiasis ossea, an overgrowth of the bones of the 
cranium. In micromegaly the condition is the reverse of that found 
in acromegaly. 

Anaemia Cerebri. — A condition in which the brain is temporarily 
or permanently deprived of part of its blood-supply. Due to: (a) 
Mechanical obstruction to the circulation, — e.g., valvular heart-lesions, 
thrombosis, embolism, or ligation of a vessel. (b) Hemorrhage. 
Classification. — (a) General or local. (&) Acute, subacute, or chronic, 
(c) Partial or complete. The membranes are pale ; small arteries over 
the gyri are empty, though large veins are full. The brain substance is 
anaemic, the surface moist, few puncta vasculosa are seen, and the cere- 
brospinal fluid is increased. 

Aneurism of Cerebral Arteries. — Classification. — (a) Single 
or multiple, (b) Large or minute. Seats. — (a) Most frequent in 
branches of the middle cerebral artery, especially those of anterior 
perforated spaces, (b) May be cortical. The aneurisms are usually 
very small, varying in size from that of a pea to a cherry-stone (sel- 
dom larger), multiple, and may resemble bunches of grapes. If 
hemorrhage occurs in basal aneurisms, the internal capsule and basal 
ganglia are injured, the lesion usually being extensive. On the cortex 
the result of hemorrhage is much less grave. 

Apoplexia Neonatorum. — A form of hemorrhage of the brain 
occurring in the new-born, usually the result of traumatism, (a) 
Accidents during labor, from forceps, etc. (b) Congenital defects 
in blood-vessels, brain, or skull, (c) May result from prolonged and 
severe normal labor. Seats. — (a) Meninges (piarachnoid) most fre- 
quently, often bilateral, and usually at the base. (&) May be between 
dura mater and skull; is accompanied by cephalsematoma. (c) May 
occupy the ventricles, (d) May occur in brain substance about basal 
ganglia, (e) Sometimes found in parietal region and Sylvian fissure, 
(i) Generally the hemorrhage is meningeal primarily, producing 
brain-lesions secondarily, such as atrophy and softening, by pressure. 



DISEASES OF THE BRAIN AND CORD ^5 

(2) Cortical hemorrhage is represented by a clot, which may be 
encysted, softened, or organized, causing more or less injury to the 
brain. (3) When the hemorrhage is between dura and skull, fracture 
is said to be always present. 

Ataxia, Hereditary (Friedreich's). — A form of ataxic para- 
plegia occurring in children and congenital in origin, (a) Heredi- 
tary, not common, (b) More common in males than in females, (c) 
Early life, (d) A specific lesion of the cord. (1) There is a gliosis 
of the posterior column of the spinal cord, due to developmental errors 
(Osier). (2) Talipes equinus occurs in both feet. (3) Lateral curva- 
ture is common. 

Ataxia, Locomotor (Tabes Dorsalis). — A chronic disease of 
the nervous system, characterized by sclerosis of the cord and brain, 
and by incoordination, with motor, sensory, and trophic disturbances, 
(a) Male sex. (b) Adult life, (c) Syphilis, (d) Wet and cold. 
(e) Sexual excesses, etc. (1) Spinal Cord. — Externally the men- 
inges are thickened and adherent. Posterior roots are atrophic and 
of a grayish tint. Internally sclerosis of the cord begins in the pos- 
terior-root zone, involving the outer layers of posterior columns in the 
lumbar region. The sclerosis gradually extends inward, involving 
successively the columns of Burdach and Goll; when the process 
reaches the upper dorsal region, it is confined to the column of Goll. 
The cord presents a flattened appearance posteriorly, the sides being 
somewhat contracted. The diseased areas are firm, grayish or grayish 
red in color, and the whole cord is often firmer in consistency. (2) 
Brain. — Changes of less consequence than in the cord may be sclerosis 
in restiform bodies, inferior peduncles of cerebellum, and certain 
cranial nerves, — the oculomotor, optic, and auditory. Atrophy of the 
optic nerve and hemiplegia may occur. Some recent writers con- 
sider paralytic dementia to be such a disease of the brain as locomotor 
ataxia is of the cord. (3) Peripheral nerves may show degeneration 
or even neuritis. (4) In later stages occur dermopathies and arthro- 
pathies, — e.g., perforating ulcer of foot, herpes, etc., Charcot's joint, 
etc. There may be evidences of loss of control of sphincters. 

Caisson Disease.— A peculiar nervous affection, the result of a 
sudden reduction of atmospheric pressure. Occurs in bridge-builders, 
divers, etc., who, after working for hours under a pressure of two or 
three atmospheres, have suddenly returned to air of normal density. 
In fatal cases there is a marked destruction of nerve tissue in the pos- 



!86 post-mortem examinations 

terior columns and the posterior portions of the lateral columns, 
forming fatty detritus and compound granular cells. 

Chorea, Acute. — (a) Female sex. (b) Early life (before the 
fifteenth year), (c) Heredity, (d) Bad hygiene, (e) Fright, (f) 
Bad habits. No constant lesions are found. Vascular changes, such 
as hyaline degeneration, leucocytic infiltration, minute hemorrhages, 
and thrombosis of small arteries, have been described. 

Congenital Anomalies. — Cranioschisis, rhachioschisis, hydro- 
meningocele, encephalocele, myelomeningocele, hypoplasia of different 
parts, as of the cerebellum, micrencephaly, hydrocephalus, internal and 
external porencephaly, idiocy, cretinism, micromyelia, total absence of 
parts, and anomalies of distribution. 

Cretinism. — A low form of idiocy, either congenital or acquired 
during the early years of life, and associated with anatomic changes 
in the thyroid gland, as absence, hypoplasia, atrophy, or goiter. It is 
endemic in certain localities, notably Switzerland, where goiter is 
prevalent. Heredity bears a causative relation. The condition usually 
appears at birth. The child is stunted and dwarfish in appearance. 
The trunk is large in proportion to the development of the head, hands, 
and feet. The head is flat, the face broad and expressionless, the eyes 
are dull and stupid, the nose is flat and depressed, the lips are thick, 
and the tongue is large and usually protrudes. The teeth are carious ; 
the hair is thin, brittle, and harsh to the touch ; the skin about the hair 
is dry and scurfy. The abdomen is prominent ; the legs are short and 
thick, the hands and feet undeveloped. The skin is yellow, leathery, 
and rough to the touch. 

Delirium, Acute. — The post-mortem findings are usually nega- 
tive. There may be great venous engorgement of the meninges, and 
the cortex and blood-vessels may show exudation and leucocytic infil- 
tration into the lymph-spaces and sheaths. Careful examination of 
the lungs and ileum should be made in fatal cases. 

Encephalitis, Acute. — Due to: (a) Acute infectious disease. 
(b) Traumatism, (c) Intoxications. The minutest foci of inflam- 
mation are not recognizable by the unaided eye; later stages have a 
pinkish appearance or are represented by clusters of small dark-red 
hemorrhagic foci. When suppuration follows, these areas take the 
form of yellowish-white patches whose tissue soon liquefies and 
becomes purulent. 



DISEASES OF THE BRAIN AND CORD 187 

HLematomyelia. — Hemorrhage into the cord, (a) Traumatism. 
(b) Exposure, (c) Convulsions, (d) Tumor, (e) Syringomyelia. 
(/) Myelitis, (g) Male sex. (h) Middle life. The cord is usually 
enlarged, occasionally lacerated. The blood is generally confined to 
the gray matter, but may escape beneath the membranes. 

Hemiplegia in Children. — Causes: (a) First or second year. 
(b) Traumatism, (c) Embolism or thrombosis, (d) Congenital 
defect. Classification. — (a) Embolism, thrombosis, or hemorrhage. 
(b) Atrophy and sclerosis, (c) Porencephalon. (1) The results of 
embolism, thrombosis, or hemorrhage depend on the extent and 
rapidity of the formation and on location. When the process is an 
acute one and extensive, it is either immediately fatal or leads to more 
or less extensive destruction of the brain substance; there is a ten- 
dency to softening or suppurative change. (2) Atrophy and sclerosis 
may involve a group of convolutions, an entire lobe, or even a whole 
hemisphere. The affected gyri are firm, hard, and atrophied, con- 
trasting sharply with the normal tissue. They may be uniform in 
appearance or there may be nodular projections. In porencephalon 
there is loss of substance, with the formation of cavities or cysts at 
the surface of the brain. 

Hemorrhage, Cerebral. — The most common cause (sixty per 
cent.) is rupture of the lenticulostriate artery. Classification. — (a) 
Basilar. (&) Cortical. In basilar hemorrhage section of the brain 
substance frequently shows miliary aneurisms, which are seen as small 
dark bodies along the course of the blood-vessels penetrating the ante- 
rior perforated spaces. Aneurism of a branch of the circle of Willis 
may be found. Endarteritis and periarteritis are found in the cerebral 
vessels. At the seat of a recent hemorrhage the brain has a dark-red, 
softened appearance, the tissue being reduced to a coagulated or pulpy 
mass of detritus. When the hemorrhage has been extensive, the 
remainder of the brain is anaemic. The gyri are more or less flattened, 
from extravasated blood, and the sulci are indistinct. Hemorrhages 
are most common near the corpus striatum towards the outer section of 
the lenticular nucleus. They may be small and limited to the lenticular 
body and internal capsule or may break into the lateral ventricle. Ven- 
tricular hemorrhage is rare. It is usually bilateral. Meningeal hemor- 
rhage is usually caused by fracture of the skull or rupture of a blood- 
vessel. The hemorrhage may be small or large. It may be above or 
below the dura or between the pia and the arachnoid. 



^8 POST-MORTEM examinations 

Hemorrhage into the Spinal Membranes. — Extrameningeal 
hemorrhage may be extensive, without compression of the cord. Rup- 
ture of an aneurism into the spinal canal may produce profuse and 
rapidly fatal loss of blood. There may be little demonstrable morbid 
change. Intrameningeal hemorrhage usually occurs in scattered areas 
as the result of acute infectious fevers. More extensive hemorrhages 
result from epilepsy, tetanus, and strychnine poisoning. Occasionally 
hemorrhage into the spinal meninges may ascend to the brain. 

Hyperemia, Cerebral. — This may be: (a) Active, (b) Passive. 
( i ) The cerebrum is congested, the blood-vessels are somewhat dis- 
tended, and petechial hemorrhages are numerous. On section the 
gray substance contrasts very markedly with the white; the former 
is of a brick-dust color; the latter shows many punctate hemorrhages. 
(2) In passive congestion the veins of the cortex are distended; the 
gray matter has a deeper color and its vessels are full. The gray mat- 
ter shows distention of the smaller veins, which on section allow their 
contents to exude as drops of blood of various sizes. Excessive 
passive hyperemia may result in cerebral oedema. 

Leptomeningitis, Acute Cerebrospinal. — Acute inflammation 
of the pia and arachnoid of the brain and spinal cord. Causes: (a) 
Acute infectious fevers, (b) Injury or disease of the base of the skull. 
(c) Extension of disease from nose, ear, or Eustachian tube, (d) 
Pyaemia. The organisms most commonly found are the meningo- 
coccus, the pneumococcus, the tubercle bacillus, and the cocci of in- 
flammation; more rarely, the bacilli of influenza and of typhoid, the 
colon bacillus, and the gonococcus. Classification. — (a) Simple or 
traumatic, (b) Purulent, (c) Tuberculous. (1) In simple or puru- 
lent meningitis the membranes are thickened, the blood-vessels dilated, 
and there is more or less exudation, which may be serous, serofibrin- 
ous, or purulent. The exudation may be so extensive as to cover up 
the convolutions. The inflammatory process is most marked in the 
basilar portions. It may be unilateral or bilateral. In the former the 
condition is due to extension from neighboring parts. (2) The 
tuberculous form of the disease is ususally cortical as well as basilar. It 
begins as a miliary tuberculosis, and in the early stages exudate is not 
extensive. The ventricles also may be involved and present consider- 
able distention and softening; they seldom suffer in other forms of 
the disease. 



DISEASES OF THE BRAIN AND CORD 189 

Meningitis, Acute Cerebrospinal. — An acute infectious dis- 
ease, especially of early life, characterized by inflammation of the 
membranes of the brain, with an exudation of fibrinopurulent material, 
chiefly towards the base, and due to the Diplococcus intracellular is. 
(1) Membranes of the Brain. — In acute fatal cases there is intense 
injection of the pia and arachnoid, with a little exudate. In more 
chronic cases there is a formation of fibrin or of pus, or of both; 
this is most marked at the base of the brain. The meninges are much 
thickened and opaque. The larger blood-vessels are overfilled and 
many of the smaller ones are obliterated. Sometimes the entire cortex 
is covered with a thick purulent exudate, and there may be much 
lymph along the larger fissures and in the sulci. In acute cases the 
ventricles are dilated, the ependymse are inflamed, and the cavity may 
contain pure pus. (2) Cranial Nerves. — The nerves usually involved 
are the second, fifth, seventh, and eighth. They are often embedded 
in the exudate. Micro-organisms may be found in the fibrin. (3) 
Brain Substance.— -This is softer than normal, has a pinkish color, 
with foci of hemorrhage and of brain softening. (4) Lungs. — Pneu- 
monia and pleurisy may occur. The lungs are often congested, with 
evidences of bronchitis. (5) Abdominal Organs. — The liver is rarely 
altered. Acute nephritis is sometimes present, and the intestines may 
show swelling of the follicles. (6) Skin. — There may be rose-colored, 
hypersemic spots, resembling the typhoid rash, urticaria or pemphigus, 
and in rare instances gangrene. (7) Eye. — Neuritis is common, and 
there may be acute papillitis. Purulent chorioido-iritis or even kera- 
titis sometimes occurs. (8) Ear. — Otitis media develops from direct 
extension, and frequently leads to abscesses. In one of my cases 
the bacillus of tuberculosis was found associated with the meningo- 
coccus. In two fatal cases examined by me there was a history of 
traumatism, though no sign of this was found at the postmortem. 
During an epidemic domestic animals, as the goat, should be watched 
for signs of disease. 

Menigq-en cephalitis ; Chronic Diffuse or Deep Chronic 
Leptomeningitis.— (a) Male sex. (b) Early adult or middle life, 
(c) Syphilis, (d) Alcoholism, (e) Certain occupations, as those of 
artists, navy and army officers, etc. The membranes of the brain are 
thickened and opaque and more or less extensively adherent to the 
cortex, which is torn on attempting to remove them. The convolu- 
tions of the brain are atrophied, especially in the frontal and parietal 



190 



POST-MORTEM EXAMINATIONS 



regions. The gray matter may be obscurely outlined. The white 
matter is firm in consistency. The ventricles are dilated and the 
ependymae granular; frequently there are areas of hemorrhage or 
softening associated with chronic arteriosclerosis. There is an increase 
in the cerebrospinal fluid. Usually sclerosis of the posterior columns, 
with involvement of the lateral, is found. There may be an extraor- 
dinary development in the lymph connective system of the brain, 
with a parallel degeneration and disappearance of the nerve-elements 
and the axis-cylinders, and finally shrinking and extreme atrophy of 
the parts involved. 

Muscular Atrophy, Progressive (Spinal). — (a) Male sex. 
( b ) After the thirtieth year. ( 1 ) Macroscopically there is great mus- 
cular wasting, beginning usually in the thenar and hypothenar emi- 
nences and thence extending to the general muscular system. In 
marked cases the subject may be reduced " to skin and bone." De- 
formities and contractures result and lordosis is almost always present. 
(2) Microscopically the muscles undergo fatty and sclerotic change 
and the terminal ends of the motor nerves are degenerated. (3) 
Examination of the cord shows the anterior roots corresponding to 
the diseased muscles to be atrophied. Neurogliar tissues show marked 
increase, most conspicuous in the anterolateral tracts. The degenera- 
tion of the gray matter extends to the medulla. Large ganglion-cells 
in the motor cortex may be wasted. In a case at Elwyn which I 
examined post mortem the diaphragm was easily seen through when 
held up to the light. 

Myelitis, Acute. — (a) Traumatism, (b) Exposure, (c) Cer- 
tain infections, (d) Disease of the spine, (e) Disease of the cord. 
(1) The cord is swollen and soft and the pia injected. On incision a 
diffluent fluid may escape. The distinction between gray and white 
matter is often lost. Hemorrhages are frequent. (2) Histologically 
the nerve-fibres are swollen, the axis-cylinders beaded, myelin droplets 
abundant, and corpora amylacea may be seen. The ganglion-cells are 
swollen, irregular in outline, and exceedingly granular and vacuo- 
lated. In the removal of the cord in these cases great care must be 
taken not to produce artefacts. 

Myelitis from Compression. — (a) Caries of the spine, (b) 
New growths, (c) Aneurism, (d) Parasites, (e) Distention of 
central canal with inflammatory liquid or blood. Changes appear first 



DISEASES OF THE BRAIN AND CORD 191 

in the white matter, the fibres of which may within six hours swell 
up and disintegrate. 

Poliomyelitis, Acute Anterior. — (a) Early life, (b) Boys 
more susceptible than girls, (c) Acute infectious fevers, (d) Proba- 
bly a specific micro-organism. ( I ) The seat of the lesion is in the 
part supplied by the anterior median branch of the anterior spinal 
artery. Cervical or lumbar portions of the cord are most often 
affected. (2) In the early stages the lesion is an acute hemorrhagic 
myelitis, with rapid destruction of the large ganglion-cells. (3) 
The nerve-fibres of the anterior roots corresponding to the ganglion- 
cells destroyed break down and disappear. (4) Certain anterior 
nerve-roots are atrophied, and the muscles innervated by them waste 
and become fatty and sclerotic. 

Raynaud's Disease. — A form of symmetrical gangrene, affecting 
especially the fingers and toes, caused by spasm and constriction of the 
small blood-vessels. 

Sclerosis, Insular (Disseminated Sclerosis). — Its cause is 
not definitely known. Is more common in the young than in the old. 
Sclerotic areas are usually small, of a grayish or whitish color, widely 
distributed in the brain and cord and in the gray and white matter. 
They are more abundant about the ventricles, the central canal, the 
pons, the cerebellum, and the basal ganglia. The patches are firm, 
dry, and sharply defined from the surrounding tissue; in some cases 
they may be less firm and not so well defined. Microscopically there 
is a marked increase of neuroglia, the medulla of the nerves is de- 
stroyed, and the axis-cylinders persist. 

Syringomyelia. — Syringomyelia is a chronic affection of the spinal 
cord characterized anatomically by the pathological formation of cavi- 
ties in its gray matter, and clinically by peculiar disturbances of sensi- 
bility associated with trophic disorders. Causes: (a) Embryological- 
malformations, (b) A gliosis, (c) Traumatism, (d) Development 
of embryonal neurogliar tissue in which hemorrhage or degeneration 
takes place with the formation of cavities. ( 1 ) The characteristic 
lesion is a cavity which forms in the cord in or near the central canal 
and extends into the gray matter of the anterior, or more frequently 
the posterior horns. It is most often situated in the cervical and tho- 
racic portions of the cord. (2) On transverse section the cavity may 
be oval, circular, or narrow and fissure-like, or it may present the 
appearance of two or more cavities independent of each other or inter- 



I9 2 POST-MORTEM EXAMINATIONS 

communicating. ( 3 ) The contents of the cavity are usually a colorless 
liquid. Occasionally it may be a yellow or brown gelatinous substance, 
or it may consist of blood and the products of its degeneration. The 
white matter of the cord in moderate cases is unaffected, but where the 
cavity is large and pressure from the sclerotic tissue has become great, 
the white matter is in its turn involved, being crowded to the periphery 
and more or less unable to carry on its functions. 



CHAPTER XVIII 

EXAMINATION OF THE NASOPHARYNX, EYES, AND EARS 

EXAMINATION OF THE NASOPHARYNX. 

In order to expose to view the upper air-passages, nasal, pharyn- 
geal, laryngeal, and accessory cavities, epiglottis, etc., Harke's 1 method 
has come into general use. If the procedure is properly carried out, 
the parts when returned to their normal position present no noticeable 
deformity, though during the examination such a result seemed almost 
impossible. 

Harke's Method. — The brain having been removed and the ex- 
amination of the skull completed, the anterior skin flap is dissected away 
from the frontal bone down to the root of the nose, while the posterior 
flap is dissected away some distance below the foramen magnum. It is 
not necessary that the primary incision of the scalp behind the ears be 
made lower than the mastoid process on each side. Next, directly in the 
median line, the skull is cleft with a small saw into two lateral portions. 
For the sake of convenience the saw markings may be divided into two 
sets (Fig. 137), the first starting from the front in the frontal bone, ex- 
tending down to the nasal bone, and continuing to the foramen magnum 
(A B), and the other starting at the occipital bone and extending to 
the foramen magnum (CD). The atlas and axis are sawed through if 
much room be desired. The sawed portions are now separated by 
means of a chisel and hammer, any portions of mucous membrane that 
may appear being severed with a knife or scissors. By means of strong 
lateral traction the two segments may be pulled apart, and the entire 
region down to the vocal cords will thus be exposed. Usually the in- 
cision passes to one or the other side of the nasal septum. The walls 
of the accessory cavities are readily cut away with strong scissors, and 
a plain view is obtained of the maxillary sinuses as well as the frontal, 
sphenoid, and ethmoid. Even the epiglottis and vocal cords can be 
examined by this method (Fig. 138). In order to view the parts 
better, light may be thrown in by means of a mirror. 

Another method is to drill holes just in front of the sphenoid and a 
little behind and to the right and left of the crista galli, and then with a 

1 Berliner klin. Wochenschrift, 1892, No. 30; Virchow's Archiv, 1891, Vol. 125. 

13 193 



194 



POST-MORTEM EXAMINATIONS 



saw or a chisel make an ovoid incision extending almost to the foramen 
magnum, and remove the portion of bone which hides the nasopharyn- 
geal cavities. (Fig. 137, P Q.) The two lateral halves are then 
brought together and wired as in Fig. 139. 

EXAMINATION OF THE EYES. 

For this purpose a triangular piece of the orbital plate of the frontal 
bone is broken through with a hammer or chisel, care being taken not to 
injure the optic nerve in the optic foramen, the remaining portion of the 
eye and the nerve being well protected. (Fig. 137, E and F.) The 
direction of the nerve can be determined by observing the situation of 
its exposed portion, and the chiselling done a small distance on either 
side of its normal position. The pieces of bone are removed with the 
nippers and the optic nerve is carefully dissected out, its cut end being 
held with the fingers or forceps. The capsule of Tenon and the fat are 
removed, and the entire eye is excised or, if this is not permitted, an 
incision is made in the sclerotica posterior to the conjunctival attach- 
ment. This requires a very sharp knife, as the tissue is extremely 
tough. A circular incision is made around the entire eye, and the 
fundus is exposed. A piece of dark cloth or cotton dipped in ink is 
placed in the remaining portion of the eye and the cavity is packed with 
cotton. 

If only a macroscopic examination of the retina and other structures 
is desired, the retina may be floated out in normal salt solution and then 
separated from the choroid. If the retina is to be fixed for microscopic 
examination, the incision should be as nearly equatorial as possible and 
the fundus placed immediately in Orth's or Miillers fluid or ten per 
cent, formalin, or fixed by exposing for three minutes to the fumes 
from a one per cent, osmic acid solution heated just to the boiling point. 
The eye is then put for twelve hours into Lindsay Johnson's mixture : 

Potassium bichromate, two and one-half per cent. . . '. 70 parts. 

Osmic acid, two per cent 10 parts. 

Platinic chlorid, one per cent 15 parts. 

Acetic or formic acid (to be added just before using) .... 5 parts. 

The gloss of the cornea disappears as soon as death comes on. 
After twenty-four or thirty hours, and often earlier, the bulbus softens 
and the cornea and retina become dull. The conjunctiva is now re- 
moved more easilv from the cornea, and the sclera which is not covered 




Fig. 137. — Method of examining nasopharynx, eyes, and ears. The sawing for opening the nasopharynx 
is done in the median line from the frontal bone, A, to the anterior portion of the foramen magnum, 
B, and from the occipital bone, Z?, to the posterior portion of the foramen magnum, C. The sawing can 
best be accomplished by standing on the table directly over the head, the finger-saw being especially use- 
ful at the beginning and the end of the operation. E and F, lines of incisions for the removal of the eyes ; 
G, situation of the ear-ossicles ; KJ I and LMNO, lines for removal of the ear-ossicles ; P and Q, drill- 
holes for saw-markings in the oval method of examining the nasopharynx. 




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Fig. 140.— Examination of the umbilical vessels. (After Nauwerck.) 



Right pulmonary arterj 




Pulmonary valves 



Left pulmonary artery 



Papillary muscle and tricuspid valve 



Fig. 141. — Examination of the ductus arteriosus. The sound is represented as introduced into the ductus 
arteriosus Botalli ; this duct usually closes about the fourth day after birth. (After Nauwerck.) 




Fig. 142. — Removal of the spinal cord of a child. 



EXAMINATION OF THE EARS 195 

by lids becomes brownish black and dry. (Orth.) According to 
Rnnge, several days after death a diffuse redness occurs in. the trans- 
parent media of the eyes of a foetus that has died in utero. The redness 
affects first the cornea and then the lens, — extending from without 
inward, — in this way indicating approximately the date of death. 

The position of the eye may be altered. Exophthalmus, or pro- 
trusion of the eye, may be caused by a retrobulbar tumor, oedema, 
hypertrophy of fat, collection of blood from hemorrhages, emphysema, 
inflammatory exudates, Basedow's disease, etc. Enophthalmus, or re- 
traction of the eye, may take place in atrophy of the fat, loss of liquid, 
as in cholera, deformity from scars, etc. The consistency of the eye 
varies, being increased in glaucoma and diminished in certain forms 
of degeneration. 

EXAMINATION OF THE EARS. 

A fair idea of the condition of the middle ear may be obtained 
simply by chipping away the roof with a chisel or biting it off with 
bone-forceps, but if a closer inspection is desired the petrous portion 
of the temporal bone and the mastoid process had better be removed 
together. 

Carry the incision from its original point back of the ear and along 
the anterior border of the trapezius about half-way down the neck. 
Reflect the flaps with their soft tissues so as to leave the bone clear. 
Begin at the apex of the petrous portion of the temporal bone and with 
a chisel laid flat break through the petrobasilar suture to the jugular 
foramen, and chisel or saw through the skull on a line from the jugular 
process of the occipital to a point about five centimetres posterior to 
the base of the mastoid process. Anteriorly chisel or saw through the 
skull on a line from the apex passing posterior to the spinous process 
of the sphenoid; or between the foramen ovale and the foramen 
spinosum and well anterior to the external meatus, just cutting off the 
root of the zygoma. 

Woodhead 1 uses the following method : 

'* The temporal bone, with its petrous portion containing the in- 
ternal ear, may be taken out and examined after removal of the brain, 
by stripping off the dura mater from the base, dissecting off the skin 
and muscle, detaching the external ear from the bone, and disarticu- 
lating the jaw; then, taking the margins of the temporal bone as the 

1 Practical Pathology, p. 28, 1892. 



196 



POST-MORTEM EXAMINATIONS 



base of a pyramid, the apex of which is a little beyond the inner 
extremity of the petrous portion, two saw-cuts are carried almost 
vertically downward so as to bound the pyramid, and then with a 
bone-chisel and mallet the whole temporal bone may be removed, after 
which it may be softened in a decalcifying fluid; or the internal ear 
may be dissected out with a small saw, a pair of sharp well-fitting bone- 
forceps, and a sharp gouge and chisel. The internal ear or tympanic 
cavity and mastoid cells may also be opened up with the aid of the 
above instruments." 

By sawing or chiselling as in Fig. 137, K J I or L M N 0, the ear- 
ossicles and internal ear may readily be reached. 



CHAPTER XIX 

POST-MORTEM EXAMINATIONS OF THE NEW-BORN 1 

In performing a postmortem on a child it is sometimes advan- 
tageous to remove the viscera en masse. To practise evisceration the 
trachea and oesophagus are divided as high up as practicable and then 
elevated with the free hand. All the posterior attachments are cut as 
close as possible to the vertebral column until the diaphragm is reached. 
This is excised laterally and posteriorly, adhesions being severed with 
the knife as before. The crura being cut loose, the diaphragm is free. 
Two ligatures are now applied to the rectum, which is then divided 
between them. When everything which holds the abdominal organs in 
place has been loosened with the hand, the organs of both the thorax 
and the abdomen can readily be removed, leaving only the bladder and 
organs of generation in situ; these may be excised later, in the same 
manner as that described for the adult on page 132. By this method 
the viscera can be more conveniently examined both anteriorly and 
posteriorly, and, as they are all attached, their normal relations are 
preserved. 

The body of a child thus disembowelled can be kept for a long time, 
especially if the abdominal cavity be packed with a mixture of equal 
parts of bran and salt, to which a little white arsenic may advan- 
tageously be added. The cadaver should then be surrounded with 
cotton and a circular bandage applied to the chest and thorax. Parental 
consent to the performance of an autopsy may sometimes be obtained 
by suggesting the employment of this method of preserving the body. 
The methods of examining the umbilical vessels and the ductus arte- 
riosus are readily seen by referring to Figs. 140 and 141 respectively. 

The removal of a child's brain is more difficult than that of an 
adult, because, first, it is much softer, and, second, the dura is normally 
adherent to the cranium. But it is easier in one thing, — the fact that 
the bones and sutures are not ossified. In a new-born child the brain 

1 For the sake of convenience, references are here added to other portions of 
this work which may be consulted when making postmortems in the new-born. To 
ascertain the intra-uterine age of a stillborn child see page 313. To determine 
whether the child was dead or alive see page 312. For weights and measure- 
ments of the child at birth see page 269. 

197 



198 



POST-MORTEM EXAMINATIONS 



is so soft that its removal without injury is almost impossible. In 
such cases it is advisable to lay the body for a short time on ice sprin- 
kled with salt, in order that the brain may become hardened by the 
cold. Another method, and one in which I have obtained the best 
results, is to place the child in a large basin or tub containing a strong 
solution of common salt (about half a bucketful to four or five times 
this amount of water) and conduct the final operation of removing 
the brain beneath the surface of the liquid, where the body is held by 
an assistant. Brine of the above strength has a specific gravity slightly 
greater than that of the brain substance, thus affording more general 
and even support and lessening the liability of damage. 

The method is as follows : The scalp is incised across the vertex 
and the flaps are turned forward and backward as in the adult. With 
scissors having well-rounded points cut through the sutures and dura 
well down to the floor. The five flaps thus formed are pulled outward 
and if necessary cut partly across their base by strong scissors. While 
the brain is being removed the body should preferably be held in the 
salt solution. Begin by removing the falx cerebri and longitudinal 
sinus, then the frontal lobes, olfactory bulbs, etc., in the usual order. 
W r hen the tentorium and falx are cut through, the brain can be pushed 
out into the solution, where it will float. If it is desired to harden 
the brain, it will be well to place a jar of Miiller's or other hardening 
fluid under it, the transfer being made from the salt solution to the 
preservative fluid without much of the solution passing into the jar, 
though the fluid should afterwards be changed for a fresh supply. 

The spinal cord may be removed from the body of a baby with 
scissors alone, as the parts are easily cut through. The lines for the 
incisions through the skin and the vertebrae are made in the same 
manner as in the adult, but neither knife nor saw is required, the scissors 
being strong enough easily to penetrate the soft bony structures of the 
vertebral column in a child under fifteen months of age. (Fig. 142.) 
In babes the spinal cord is relatively much more firm than the brain. 

In autopsies on babes suspected of being the victims of hereditary 
syphilis it is often important to look for the fatty changes produced 
by that disease at the junction of the cartilage and the bone in the 
femur. For this purpose a longitudinal incision is made directly over 
the head of the os femoris and the soft parts are dissected until the bone 
is reached. The ligaments are then incised and the head is disarticu- 
lated. The shaft is held by the left hand securely wrapped in a towel 



POST-MORTEM EXAMINATIONS OF THE NEW-BORN 



199 



while a perpendicular incision through the cartilaginous head is made 
down to the bone; should this be much ossified, the incision may be 
continued with a saw. After sawing for about two inches, a knife is 
introduced and one segment is broken off. The presence of a yellowish 
area of fatty degeneration, more conspicuous in the osseous portion 
than in the cartilage, show r s an interference in the nutrition of the part 
which is quite characteristic of hereditary syphilis. (Figs. 143 and 
144- ) 



CHAPTER XX 

RESTRICTED POST-MORTEM EXAMINATIONS 

In case permission to open the thorax is refused, the diaphragm 
may be severed from its anterior attachments, and the lungs, the heart, 
and even the tongue and adjacent parts may be removed en masse 
through an abdominal incision or a laparotomy wound. 

Should the avoidance of visible mutilation be imperative, it is pos- 
sible to examine and, if necessary, to remove both the abdominal and 
thoracic viscera through the rectum or perineum in males or through 
the vagina in females. In the male this procedure is performed in the 
following manner : 1 

The body is placed on the back, with the buttocks very near the 
end of the table and the thighs widely separated and flexed upon the 
body. The scrotum is then well drawn up, and an incision is made 
from the perineo-scrotal junction to the margin of the anus and down 
to the bulb. The knife is carried around this and through the sub- 
jacent tissue to the pelvic fascia underlying the vesicorectal pouch, 
without injuring the bladder or rectum. The left arm being bared to 
the shoulder, the hand is introduced through the incision, and gradually 
forced up between the parietal peritoneum and the rectus muscles to 
the diaphragm. The peritoneum may be opened, but the intestines will 
invest the hand like a tightly fitting glove and make the manipulation 
more difficult. If unable to perforate the diaphragm with the fingers, 
a scalpel may be carried up, with the blade flat against the index-finger, 
and a nick made in the muscle, the knife being then withdrawn and the 
opening enlarged with the fingers. The lungs may be examined by 
palpation, any adhesions broken up, and the organs dragged into the 
abdominal cavity, the roots being severed with a knife, after which 
they may be removed. The heart can be examined in a similar manner, 
except that, before it can be moved very far, scissors or a knife will be 
necessary to sever the large vessels. The kidneys, adrenals, spleen, 
stomach, etc., may be removed in this manner, but the liver must gen- 
erally be divided into its lobes in order to get it through the incision. 
The organs are examined in the usual manner and returned to the 
body; some wads of oakum may then be pushed into the abdominal 
cavity and the perineal incision very carefully closed by hidden sutures. 

1 H. A. Kelly, Medical News, June 30, 1883. 



RESTRICTED POST-MORTEM EXAMINATIONS 2 OI 

It is also possible to make the examination through the rectum, but the 
sphincter is left dilated and gaping, presenting a much more con- 
spicuous and unsightly appearance than the perineal incision. 

This method is most difficult of accomplishment when the operator's 
arm measures more than ten or eleven inches around the biceps, espe- 
cially in subjects of only average size. The work is very arduous, 
because of the strained and cramped position which the hand and arm 
must assume in order to pass the promontory of the sacrum. Coplin 
suggests the use of the photographer's thimble in tearing the tissues 
within the abdominal cavity. 

Access to the interior of the trunk may readily be had from the 
dorsum by making a longitudinal incision to one side of the spinal 
column and sawing the ribs close to their vertebral attachments. When 
the examination is made through the vagina, an oval incision such 
as is described on page 132 may be made, or a vaginal hysterectomy 
may first be performed (Figs. 89 to 93 inclusive). 

The brain may be removed almost intact (in two or three pieces) 
by making a transverse four-inch incision across the fifth cervical ver- 
tebra, dissecting up the soft tissues, and cutting a V-shaped segment 
out of the occipital bone by introducing a saw through the foramen 
magnum and sawing towards the ears and then across transversely. 
(Fig. 130, E A F.) My rapid method of diagnosing hemorrhage also 
permits of the removal of the brain in small pieces. (See page 

1 79-) 

An examination of the bones of the face is sometimes desirable, but 
the circumstances and conditions under which it may be required are 
so variable that the method must be left entirely to the judgment of 
the operator. Disfigurement is so readily noticed that nothing further 
than a superficial examination should be attempted without the per- 
mission of those interested. The simplest and most unobjectionable 
method of procedure is to introduce the knife through an incision pre- 
viously made from the ear to the neck and dissect subcutaneously the 
tissue investing the bony structures. If the bones of the face are to 
be removed, it may be necessary to make a transverse incision, the point 
of election being the furrow between the inferior maxilla and the neck. 

If the oral cavity must be examined through the orifice of the mouth 
after rigor mortis has set in, the rigidity may be overcome by placing 
towels soaked with hot water over the muscles of the jaw. Such appli- 



202 POST-MORTEM EXAMINATIONS 

cations repeated for about five minutes usually suffice. Do not use a 
chisel to pry the jaws apart, as is sometimes recommended, because of 
the danger of breaking the teeth or knocking them out. As the rigidity 
rarely returns, it is advisable at the end of the examination to close the 
mouth with a few sutures through the mucous membrane of the upper 
and lower lips. 

The nasal cavity may be exposed and examined by detaching with 
a knife the upper lip from the maxilla from within and then removing 
with a saw such portions of the superior jaw-bone as will afford room 
for inspection of the parts under consideration (Figs. 145, 146). By 
the removal of the eye the pituitary body, Gasserian ganglion, etc., are 
rendered easily accessible. Indeed, it is surprising what extensive dis- 
sections may be made in the region of the face and neck in the ways 
just mentioned, thus affording an opportunity for thorough digital 
examination of areas not open to ocular inspection. 



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3 g 






Fig. 145. — Method of examining nasal cavities, antrum of Highmore, etc. By means 
of a knife the uppermost mucous membrane between the lip and the superior maxilla is 
incised, the upper lip being elevated with the left hand during the incision. Vertical 
sawing is now done in the median line, and the tooth extracted at the point where the 
lateral sawing is to take place. The bone-forceps readily bring the desired portion of 
bone away, or it can be loosened by means of a chisel. 




Fig. 146. — Appearance of the part after removal of a portion of the superior maxilla for 
the purpose of examining the nasal cavities, antrum of Highmore, etc. 




Fig. 147. — Method of sewing up the body. 




Fig. 



148.— Appearance of body after it has been sewed with base-ball stitch. The sewing has been done from above 
downward, and there is no puckering at the point of starting. 




Fig. 149. — Slee's method of fixing the skullcap. 




Fig. 150. — Author's method of holding skullcap in place. Four holes are drilled [in the 
hones on each'side, two to the right and left of the angle in the temporal bone and two in 
the skullcap just above the angle. Saw-cuts to hold the wire or string are made in the vertex, 
the string being thrust in and out of the openings and tied at any convenient spot. 



CHAPTER XXI 

RESTORATION AND PRESERVATION OF THE BODY 

When the examination has been completed, the cavities of the body 
should be thoroughly sponged out, all blood and other fluids removed, 
and bleeding vessels tied to prevent leakage. The organs should then, 
as nearly as possible, be returned to their respective positions, and the 
cavities filled with dry bran, absorbent cotton, sawdust, sea-weed, or 
shavings, in sufficient quantity to restore the original contour of the 
body, covering the abdominal contents with old cloth or papers to pro- 
tect the under surface of the seam. The brain is generally put into the 
abdominal or thoracic cavity, owing to the great difficulty in returning 
it to the skull. If several postmortems be made at the same time and 
place, care should be taken to return the organs to the proper body, nor 
should a cadaver be used as a convenient receptacle for the disposal of 
specimens which are no longer of any use. The late Dr. Formad told 
me of a case where three livers were found in a body previously posted 
in one of our Philadelphia hospitals and disinterred for suspected poi- 
soning. In the case of a child a small bag may be packed with sand or 
sawdust so as to assume the shape of the brain and placed inside the 
calvarium ; the brain itself, after dissection, is placed in the abdominal 
or thoracic cavity. 

In all private cases it is important to secure the skullcap in position, 
tc prevent the unsightly disfigurement produced when it slips after the 
scalp has been sutured. A number of efficient methods have been 
devised, but the one selected usually depends upon circumstances or 
upon ingenuity. The fossae of the skull as well as the calvarium may be 
filled with plaster of Paris, and while the plaster is still soft a short, 
stout stick of wood is pushed through into the foramen magnum, the 
upper end extending to the skullcap, which is then adjusted. When the 
plaster hardens, the calvarium is well fastened in good position. If in 
removing the calvaria the precaution is taken to crack at least a part 
of the inner table with the chisel and hammer, projecting pieces of bone 
are usually left, which interlock and hold the calvaria snugly in position 
when it is replaced. 1 If the edges of the temporalis have not been too 
badly lacerated, sutures may be passed through the muscle and fascia 

1 Mallory and Wright, Pathological Technique. 

203 



204 



POST-MORTEM EXAMINATIONS 



with very satisfactory results. Small holes may be drilled in the skull 
and sutures passed through them, or a wide staple (or double-pointed 
carpet- tack) may be used for the same purpose. Another method is to 
drive a small wire pin, or a wire nail with its head cut off, about half 
an inch long, half-way into the diploe of the skull and insert the other 
end in a hole, made to correspond, in the calvarium. Two of these pins 
should be enough. Still another method is that described by Slee. 1 The 
posterior line of sawing, instead of stopping at the angle, is continued 
an inch or more into the temporal bone; a piece of ordinary roller 
bandage is then stretched across the skull and inserted in the saw-cut ; 
the calvarium is replaced, the ends of the bandage are brought together 
over the vault and securely sewed, pinned, or tied (Fig. 149) . A ready 
and efficient method of my own for fixing the skullcap is to make in two 
or three places on the thickest portions of the skull vertical pencil-marks 
across the line of sawing and extending an inch above and below it, 
saw these for three-quarters of an inch or so, and into each pair of saw- 
cuts insert the ends of a thin double-wedge-shaped piece of iron or 
steel so made that it will be tightly pushed into place when the skullcap 
is affixed. Any portion projecting beyond the bone is hammered down. 
For another method see Fig. 1 50, 

If the vault of the cranium is to be retained by the physician 
and a substitute cannot be found, take a square piece of pasteboard 
about three millimetres thick (thinner for children) and soak it in 
warm water for a quarter of an hour, or until it is soft enough to be 
easily moulded over the skullcap. Having done this, cut the paste- 
board parallel to the edges of the saw-cuts and overriding them from 
ten to fifteen millimetres. Then fill the skull cavity with wadding 
or plaster of Paris. Remove the pasteboard from the skullcap just 
as soon as it becomes so dry that when it is applied to the base of the 
skull the edges will adapt themselves to the border thereof. With a 
knife the edges of the pasteboard are cut obliquely, any folds which 
are formed therein are incised along their crests, one edge is tucked 
in under the other, and the surface smoothed by the use of the knife. 
Strong twine is bound twice around and the pasteboard thus securely 
fastened to the base of the skull. The temporal muscle is drawn up- 
ward and the skin stitched over the whole as in the usual way. ( Nau- 
werck. ) 

1 Medical News, December 31, 1892, p. 737. 



RESTORATION AND PRESERVATION OF THE BODY 205 

The skullcap being secured, the scalp is replaced and sutured with 
glover's or base-ball stitches, — i.e., those made by repeatedly passing 
the needle from within outward. By careful use of black or dark 
thread the incision may be so neatly closed as to escape even fairly 
close inspection. It sometimes happens that by stretching the skin 
becomes baggy. A small portion of the hairy scalp may then be re- 
moved previous to the sewing. 

After the organs are returned, the sternum should be supported 
by paper, or, still better, by old linen. Bran and fine sawdust are very 
useful to fill in with, as they absorb the moisture. Oakum makes the 
sewing difficult. Formad used to tell of a disastrous though amusing- 
result which occurred from the use of a large quantity of self-raising 
buckwheat flour for this purpose. 

If the organs have been removed through the vagina or rectum, 
these outlets should be doubly sewed, some absorbent material having 
first been introduced to prevent leakage. 

A round stick or a piece of gas-pipe may be placed in the spinal 
canal after the removal of the cord, with the upper end pushed through 
the foramen magnum, especially if any of the vertebrae have been 
taken away, and plaster of Paris may be poured in until the cavity- 
is well filled. An old cloth or some paper is then placed on top and 
the whole sewed together. The line of the incision may be covered 
with a strip of adhesive plaster. 

The abdominal incision is closed by sewing from the pubes to 
the sternum, passing the stitches from within outward, about three- 
eighths of an inch from the cut edges and about half an inch apart, 
alternating on the two sides so that each needle-hole on one side 
will be midway between two on the opposite side. The twine should 
be about half a millimetre thick. Both ends of the suture should be 
securely tied. For the closing stitch it is well to cut the thread near 
the needle, withdraw one end, and tie in a surgeon's knot. Roughly 
estimated, the thread required is twice the length of the incision to 
be closed. Carefully crowd in any extruding fascia and avoid pucker- 
ing of the part. (Figs. 147, 148.) 

If the mouth has been opened, or any of the tongue removed with 
the structures of the neck, the lips may be held together by a few 
sutures passed through the oral mucous membrane. 

If any portions of bone have been excised, their place may be sup- 



206 POST-MORTEM EXAMINATIONS 

plied by using a properly shaped piece of wood, which is held in 
position with sutures, wire, or strong cord, or by plaster of Paris. 

Lastly the body should be very carefully cleaned and returned to 
the place and position in which it was found. 

The characteristic " post-mortem odor" is very persistent and de- 
fies allkinds of soap. It usually results from handling the intestines, 
and can best be removed by washing the hands with aromatic spirit 
of ammonia or, in the absence of that, by rubbing them with dry 
mustard and then washing with soap and water, or, still better, with 
some of the newer liquid antiseptic soaps. 

Ammonia or the aromatic spirit thereof will remove iodin stains, 
while carbol-fuchsin and other anilin stains yield to a weak solution 
of sodium hypobromite. 

EMBALMED AND FROZEN BODIES. 

It has become an almost universal custom to preserve bodies by 
embalming or freezing very soon after death, a process which often 
interferes with the work of the pathologist as well as with that of 
the toxicologist. The appearance of the body in such cases will, of 
course, depend very largely upon the fluid used. Fortunately, the old 
zinc, mercurial, and arsenical combinations have been very largely 
superseded by formalin, a much more desirable preparation, although 
it may irritate the eyes, deaden the sensibility of the finger tips, and 
even produce an eczema of the hands. 

If it is impossible to make the autopsy at once, preservatives may be 
injected into the body to keep it until such time as convenient. For 
this purpose, about three hundred cubic centimetres of a five per 
cent, solution of formalin are sufficient. The fluid may be introduced 
through the arteries (arterial embalming), or a coarse trocar and 
cannula may be driven deeply into the tissues and the cavities and 
organs injected (cavity embalming). 

The former method is usually practised by opening one of the 
large superficial arteries, as the femoral, and forcing the fluid through 
the vessels. Nauwerck uses the following instruments : an injection- 
syringe with a capacity of five hundred cubic centimetres; long can- 
nulas of different calibers, with pear-shaped ends and with stopcocks 
or, preferably, with double stopcocks; strong twine; scalpels, scis- 
sors, forceps, grooved director, hsemostats, an aneurism-needle, and 
ordinary needles; basins and buckets; several packages of absorbent 



EMBALMED AND FROZEN BODIES 207 

cotton ; cloths and sponges ; and ten litres of a one per cent, watery 
solution of corrosive sublimate, which may be kept in one-litre bot- 
tles. His method of embalming is begun by exposing the lower part 
of the abdominal aorta and the two iliac arteries. Two ligatures are 
placed beneath the aorta, about two finger-breadths apart, and the 
aorta is obliquely incised to allow the entrance of the cannula, which 
is secured by tying the distal ligature over it. The injection into the 
upper part of the body is then begun carefully and slowly, pausing 
occasionally when the counter-pressure becomes too great. About 
three litres are injected, more or less, depending upon the appearance 
of swelling of the face, seen first about the eyes and chin. The can- 
nula is removed, both proximal and distal ligatures are tied, and the 
aorta is cut through. In like manner a litre of the solution is injected 
into each leg through the common iliac artery. A cannula with a 
double stopcock can be used to inject both the upper and lower parts 
of the body at the same time. The mesentery is ligated, and the intes- 
tines, from the beginning of the jejunum to the end of the sigmoid 
flexure, are removed, opened, washed out, and put in a one per cent, 
solution of bichloride of mercury, and later replaced in the abdominal 
cavity, wrapped in sublimated cotton, or, where practicable, disposed 
of by cremation. The stomach, duodenum, and rectum are cleaned 
out with sublimate solution and packed with sublimated cotton. The 
bladder, vagina, external ear, and nose are similarly treated. The 
abdominal cavity is carefully wiped with a cloth wrung out of the 
bichloride solution and dried, and the abdominal incision is sewed. 
The surface of the body, with the exception of the hair, is also wiped 
with the solution and dried. If this method fails, Nauwerck injects 
into the carotid and axillary arteries. 

Hewson x recommends the following preservative injection for the 
embalming of human bodies : 

& Sodium arsenate 2 kilogrammes. 

Boiling water 7850 cubic centimetres. 

Boil until complete solution, then add 

Glycerin 2000 cubic centimetres. 

Formalin 100 to 150 cubic centimetres. 

About two and one-half gallons of this fluid are introduced into an 
artery — say the common carotid — by gravity, openings having pre- 

1 Philadelphia Medical Journal, October 27, 1900. 



208 POST-MORTEM EXAMINATIONS 

viously been made in the toes or in several of the veins if they be 
distended with blood. After injection the body is thoroughly greased, 
covered with paper, bandaged, and placed in cold storage until wanted 
for dissection. 

Frozen bodies should not be thawed hastily by the addition of 
warm objects, but should be allowed to remain in a warm room for 
some twelve hours previous to the post-mortem examination. Figs. 
151 and 152 show the refrigeration room of the Medical Department of 
the University of Pennsylvania, planned by Dr. Holmes, in which when 
teaching in that institution I kept the cadavers used in illustrating 
my lectures. The bodies were removed during the afternoon pre- 
ceding the performance of the autopsy the next morning. 

In cavity embalming the instrument is thrust preferably through 
the umbilicus, so that the wound of entrance will not be conspicuous, 
and efforts are made to puncture the intestines in as many places 
as possible and to penetrate the heart, lungs, and liver; blood is then 
withdrawn, the gas escapes, and the fluid is injected. The disad- 
vantages of this method are : first, in cases of abortion with peri- 
tonitis there may be considerable difficulty in determining whether 
the markings were made before or after death; secondly, such punc- 
tures may also complicate matters by opening up abscess-cavities, 
cysts, aneurisms, etc. ; and thirdly, in cases of poisoning, besides 
allowing the stomach contents to escape, the fluid may contain the 
same substance as that which caused death. Even when formalin has 
been employed, as in the recent Haines case in New Jersey, the syringe 
may have been previously used for injecting an arsenical preparation. 




Fig. 151. — Refrigerating room. A, recording thermometer and middle tier of shelving; B and D, tiers of 
shelving ; C, brine tank ; E, pipes of refrigeration apparatus. 




ig. 152.— Preparation of bodies after removal from refrigerating room. A< bath ; B, air-condenser and injecting 
apparatus; C, pulley suspension apparatus ; I), exterior of refrigerator box ; E, odorless excavator barrels. 




Fig. 153.— Post-mortem examination of guinea-pig, made in Ravenel pan. Near the four corners 
(not seen in the illustration) are hooks upon which the chains are fastened in order to hold the animal in 
position. 



CHAPTER XXII 

DISEASES DUE TO MICRO-ORGANISMS, PARASITES, AND H^MATOZOA 

The number of diseases known to be due to vegetable and animal 
parasites is constantly on the increase, the study of tropical diseases 
especially having in recent years received marked attention and added 
much to our knowledge on this subject. The lesions which are pro- 
duced by these agencies and found post mortem are varied, though 
rarely characteristic, and require special bacteriological and histological 
training for their study and elucidation. 

Actinomycosis. — A chronic, infectious disease, which occurs most 
frequently in cattle (as "lumpy jaw" or "wooden tongue"), but is 
found also in man; it is characterized by the formation of small 
nodules, which break down and infiltrate the surrounding tissue. The 
exciting cause, the Streptothrix actinomyces (ray- fungus), is found in 
the form of yellowish opaque granules, — called sulphur balls, — which 
measure from one-half to two millimetres in diameter. When these 
masses are crushed and placed under the microscope, they give the 
appearance so beautifully depicted (in 1856) by Lebert in his Atlas. 
The organism is introduced into the body with food, often through the 
medium of carious teeth. In one case reported the patient had been 
accustomed to pick his teeth with a straw. The most common loca- 
tions of the lesions are: I. Alimentary canal. II. Lungs (lesions 
are usually unilateral), (a) Chronic bronchitis, (b) Miliary nodules 
formed by masses of fungi surrounded by granulation tissue, (c) 
These nodules may fuse, forming abscesses and finally cavities, (d) 
Bronchopneumonia. III. Heart, emboli and localized parenchymatous 
myocarditis. IV. Thorax, (a) Erosion of vertebras, (b) Necrosis 
of ribs and sternum. V. Skin, (a) Subcutaneous abscesses, (b) 
Chronic ulceration, which may last for years. VI. Primary infections 
of the brain, liver, and vermiform appendix have been described. The 
characteristic primary lesion is a small nodule resembling that seen in 
an anatomical wart. Later there occurs, especially in the lower jaw, 
proliferation of cells into surrounding tissues similar to those seen in 
osteosarcoma; this is followed by suppuration. The abscesses are at 
first multiple, spherical, and discrete; later they coalesce and give a 

14 209 



2io POST-MORTEM EXAMINATIONS 

reticulated and honeycombed appearance to the part affected. Metas- 
tases may occur. 

Anthrax. — An acute, infectious, contagious disease, more com- 
mon in the lower animals than it is in man, caused by the Bacillus 
anthracis, and having for its characterstic lesion a pustule. Certain 
animals are predisposed, especially sheep and goats, though the An- 
gora sheep is apparently immune. In man the disease is contracted 
in certain occupations, as wool-sorting, tanning, etc., and by the inges- 
tion of the flesh or milk of an infected animal. The Bacillus anthracis 
is a rod-shaped micro-organism, from two to twenty-five microns in 
length, non-motile (thus distinguished from the similarly shaped but 
motile Bacillus subtilis) , often united, and grows with great rapidity. 
Characteristic cultures may be made on gelatin plates at ordinary tem- 
peratures. The bacillus is easily killed, but the spores are very resist- 
ant. For seven successive years Ziegler was able to produce anthrax in 
mice by inoculations from similarly prepared pieces of dry catgut which 
contained the spores. Two sets of lesions are found, depending upon 
the method of invasion, — by skin or mucous membranes. I. External 
Anthrax. — (i) Malignant pustule. At the site of inoculation appears 
a papule which rapidly becomes a vesicle; later a brown eschar is 
formed, surrounded by small vesicles and an extensive area of brawny 
induration. The neighboring lymphatics are swollen, tender, and hard. 
(2) Malignant anthrax oedema. This is an extensive oedema affecting 
the eyelids, the head, arm, and often the entire upper extremity. It 
may terminate in gangrene, enteritis, peritonitis, or endocarditis. II. 
Internal Anthrax. — (1) Thorax. Very soon after death the upper 
extremities, both anteriorly and posteriorly, become dark purple, the 
nails are blackish blue, and dark chocolate-colored fluids issue from the 
mouth and nose. The cellular tissues of the upper part of the chest 
are emphysematous and crackle on pressure. On opening the thorax 
these tissues are often found infiltrated with blood and a gelatinous 
effusion. The pleurae contain much serum (two or three pints), the 
right more than the left. The pericardial fluid is also increased (six or 
eight ounces). The lungs are engorged with dark-colored blood. 
Some portions are cedematous, others harder than normal and of a 
darker-red color. The bronchial glands are swollen, hemorrhagic, and 
friable. The heart-muscle is dark colored, soft and flabby; the heart 
may be empty or contain dark, semifluid blood in all its cavities. The 
lining membranes of the heart and larger blood-vessels are stained a 



MICRO-ORGANISMAL DISEASES 211 

color varying from cherry-red to dark chocolate, according to the time 
which has elapsed since death. The serous membranes throughout 
show extravasations of blood. (2) Abdomen. The intestines show 
lesions consisting of dark infiltrated spots (phlegmonous inflamma- 
tion), about the size of a dime, with a greenish or grayish slough in the 
centre, which are composed mainly of anthrax bacilli situated chiefly 
in the lumen of the blood-vessels (Strumpell). The cavity contains 
considerable serum or there may be gelatinous cedema; hemorrhages 
appear in the serous membrane. The liver shows less change than any 
other organ ; it may be normal. The spleen may be larger than natural 
or normal in size and appearance. (3) Kidneys. The parenchyma is 
gorged with dark blood, and hemorrhages appear in the capsule. (4) 
Brain and spinal cord. Extravasations of blood are discovered between 
the membranes and sometimes small infarcts are found. In a recent 
case which I had the opportunity of studying with Dr. Morton, the 
pustule was on the palm of the hand. The disease was probably 
contracted from a bone fertilizer while working with a trowel in the 
garden. Early excision of the pustule, with the application of carbolic 
acid to the wound, was followed by recovery. (5) Retropharyngeal 
abscess may be of this origin. 

Beriberi. — An infectious disease of tropical and subtropical coun- 
tries, characterized by muscular pains and weakness, disseminated 
neuritis, cardiac failure, and general anasarca. Little regarding its 
origin is definitely known. Various micro-organisms have been sug- 
gested. Overcrowding and a fish diet may predispose. Two types, 
the cedematous and the paralytic, are recognized. The special lesion 
appears to be in the peripheral nerves. They are swollen and hemor- 
rhagic, but at times appear normal. The lesion is a parenchymatous 
neuritis. Atrophy of striated muscles may appear, in which case they 
are dry and shining, or the affected muscles, including the heart, are 
pale, flabby, and fatty. Evidences of general anasarca, affecting the 
upper extremities most, are present. 

Cholera Asiatica. — An acute infectious disease originating in 
Eastern countries, characterized by the presence of spirochseta and by 
a profound inflammation of the bowel. The comma bacillus of Koch 
is a motile, screw-shaped micro-organism about half the length of a 
tubercle bacillus, but thicker. The bacilli are found in large numbers 
in the rice-water stools, but rarely in the vomit. The position of 
the body is characteristic, the extremities being flexed, the fists 



212 POST-MORTEM EXAMINATIONS 

closed, and the abdomen scaphoid. There is cyanosis of the skin. 
( i ) In very acute cases the intestinal lesions are not characteristic, 
but the bowel contains large quantities of " rice-water." In more 
protracted cases the bowel presents a mapped appearance, — some 
areas hypersemic and some anaemic, some hypertrophic and others 
ulcerated. The inflammation is well marked in the Peyer's patches. 
The serous membrane is sticky and of a rosy color. The blood-vessels 
are prominent and the body looks thin and shrunken. The mesenteric 
glands are swollen, soft, and of a reddish color. (2) The stools 'are 
largely serous and contain masses of columnar epithelial cells and 
almost pure cultures of the micro-organism. (3) The kidney is swol- 
len, of a violet hue, and shows the changes of acute diffuse nephritis. 
(4) The liver shows little alteration except cloudy swelling, with 
minute areas of focal necrosis. (5) The heart is flabby. Its right 
side is usually distended with tarry blood. The left heart is usually 
empty. (6) The lungs are collapsed and show marked congestion at 
their bases. Pneumonia and pleurisy may develop, and abscesses are 
not uncommon. (7) There is a decided tendency to the formation of 
diphtheritic exudate on mucous membranes, particularly in the throat. 
(8) The cceliac ganglion is hyperaemic or even hemorrhagic (Roki- 
tansky). (9) All the abdominal organs are very 'dry. 

Dengue. — An acute infectious disease, prevalent in our Southern 
States, and generally known as " break-bone fever." It is bacterial in 
its origin; a therapeutic serum being now made like the antitoxin of 
diphtheria. The large and small joints become red and swollen. There 
is commonly a rash, but this has no distinctive character. General 
enlargement of the lymphatic glands is not uncommon. Being rarely 
fatal, no detailed observations have been made regarding the patholog- 
ical anatomy of this disease. 

Diphtheria. — An acute infectious, contagious disease, charac- 
terized by the presence of the Klebs-Lofner bacillus and of a false mem- 
brane. This bacillus is a non-motile micro-organism which, when 
grown on blood-serum, assumes a great variety of shapes. It is easily 
cultivated on albuminous media in from twelve to sixteen hours. The 
bacillus is fairly resistant, and will live for months under favorable 
conditions. Many other organisms produce a similar membrane, and 
the identity of this organism with the pseudobacillus of diphtheria, 
the bacillus of scleroderma, and the organism of ozsena is believed by 
many, but the subject is still sub judice. The presence of the organism 



M1CRO-ORGANISMAL DISEASES 



213 



in well persons is a fact of great interest. The forms of the disease are 
nasal, pharyngeal, laryngeal, and cutaneous. The characteristic lesion 
of diphtheria is a false membrane, beginning early as a slightly raised, 
opaque, whitish-yellow spot on the mucous membrane. As a rule, it 
grows rapidly, becoming thicker, of a grayish or greenish hue, and 
firmly adherent to the underlying tissues. In the early stages if an 
attempt be made to remove it, there is left behind a raw bleeding sur- 
face. In the later stages the membrane becomes less firmly adherent, 
soft, shreddy, and somewhat easily detached. The diphtheritic patches 
may become hemorrhagic, the color being then dirty brown or grayish 
green. The blood not only infiltrates the submucous layer but also 
the pseudomembrane. When the submucous layer and the surround- 
ing connective tissue become markedly infiltrated, the inflammation is 
said to be phlegmonous. There is great swelling and pus soon forms. A 
retropharyngeal abscess may be of diphtheritic origin. In nasal diph- 
theria the membrane may be slight in extent or may entirely block up 
the nasopharynx. It is apt to lead to extension of inflammation to 
the membranes of the brain. In the pharyngeal form the exudate is 
usually first seen on the tonsils. It is apt to be very extensive and 
extend into the mouth, the oesophagus, and even the stomach. In the 
laryngeal form the amount of exudate is often very great : it may 
entirely occlude the air-passages and extend to the lungs and the 
bronchial tubes, even to those of the third and fourth dimensions, but 
as it extends it gets softer and thinner. In this form the pharynx may 
be entirely free from membrane. The cutaneous form is somewhat 
less common; it is apt to occur about wounds, the false membrane 
being seldom extensive. In nearly all cases of diphtheria there is 
marked inflammation of the neighboring lymphatic glands and often 
of the salivary glands. There is apt to be a bronchopneumonia. There 
are small atelectatic patches surrounded by areas of inflammation. 
Should the diphtheritic membrane become gangrenous, the process is 
liable to extend to the lung. Klebs-Loffler bacilli are usually not found, 
but cocci of various kinds are numerous. Endocarditis is extremely 
rare, but changes in the fibres of the heart-muscle are comparatively 
common. The serous -membrane often shows ecchymoses. The kid- 
neys always show more or less diffuse inflammation, which may be 
hemorrhagic, and albuminuria is a constant symptom of the disease. 
The other organs show the ordinary febrile changes. In malignant 
cases the micro-organisms may be found in the bladder and the internal 



214 



POST-MORTEM EXAMINATIONS 



organs. As a rule they do not penetrate below the submucosa at the 
site of the lesion. Orth describes an enteritis nodularis in which the 
follicles and Peyer's patches are markedly swollen and hypersemic. 
Growths may occur in various mucous membranes, as in the eye, the 
oesophagus, the vagina, in exstrophy of the bladder, etc. 

Erysipelas. — An acute contagious disease, characterized by a 
rash, and due to the Streptococcus or Diplococcus erysipelatis. The 
micro-organisms gain entrance through a wound or abrasion of the 
skin or mucous membrane. Three types of erysipelas are noted, — sim- 
plex, ambulans, and phlegmonosum. In uncomplicated forms little 
more than an inflamed oedema is seen. The micro-organisms can be 
found post mortem in the lymph-spaces and in the zone of spreading 
inflammation. In severe forms the face is enormously swollen, the 
eyes are closed, the lips ©edematous, the ears thickened, and the scalp 
swollen. Blebs and vesicles often appear upon the eyelids, ears, and 
forehead. Small cutaneous abscesses about the cheeks, forehead, and 
neck are common, while beneath the scalp large quantities of pus may 
accumulate. There is enlargement of the cervical glands, but this is 
masked by the oedema. Erysipelas of the phlegmonous type may ex- 
tend to the intermuscular fascia. It is then likely to be gangrenous, 
particularly when following hemorrhagic contusions. This form, be- 
sides being the cause of acute purulent oedema, may result in emphy- 
sematous inflammation when gas-producing germs are associated. 
Infarcts often occur in the lungs, spleen, and kidneys ; these are usually 
septic in character. Endocarditis ulcerosa is particularly common. 
Albuminuria is a constant complication, but true nephritis is only occa- 
sionally seen. Septicaemia, septic pericarditis, and pleuritis are of com- 
paratively frequent occurrence. Acute atrophy of the liver sometimes 
occurs. 

Fever, Glandular. — An infectious disease of childhood, charac- 
terized by marked enlargement of the cervical glands. It is bacterial 
in origin and occurs between the ages of one and ten years. The dis- 
ease is rarely fatal. The cervical glands are swollen and softened; 
they seldom suppurate, and the adjacent skin and mucous membrane 
show no marked changes. 

Foot-and-mouth Disease. — Stomatitis aphthosa epizootica is an 
acute contagious disease, occurring most frequently in cattle and sheep, 
but found also in persons who come in contact with the disease in ani- 
mals. It begins as a small vesicle (which is at first clear, later grayish) 



MICRO-ORGANISMAL DISEASES 21 5 

on the lips, cheeks, or pharyngeal mucous membrane. When the vesicle 
reaches a diameter of from one and a half to three centimetres, it bursts, 
leaving a shallow ulcer, with oval, circular, or irregular edges. The 
affected mucous membranes are inflamed, swollen, and cedematous, and 
there is considerable exudate. The lesions are also found on the udder 
and feet, usually appearing after the eruption in the mouth. The post- 
mortem appearances are most varied, consisting in cedema, hemor- 
rhagic infiltrations, fatty changes in the parenchymatous organs, etc. 
Loftier and Frosch consider the disease to be due to an organism so 
minute that it passes through the finest filters and is even not visible 
with the best of our present microscopes. A colored illustration of the 
lesion is seen in Kitt's Atlas der Thierkrankheiten, 1896. 

Frambcesia. — Yaws is a contagious disease of the skin, character- 
ized by an indefinite period of incubation and the presence of dirty 
or bright red-raspberry-like tubercles. It is presumably of microbic 
origin. The eruption begins as a papule, usually at the site of an old 
wound. In a few days the papules are scattered over the body; they 
rapidly enlarge and become tubercles, which are generally circular in 
shape, and vary in size from that of a pin's head to a small apple. The 
epidermis splits or cracks, exposing a raw granulating surface, which 
rarely ulcerates. The disease is by some supposed to be a modified 
form of syphilis. In his excellent work on Tropical Diseases, Man- 
son states that the question of their identity is certain to be debated 
until the respective germs of yaws and syphilis have been separated, 
cultivated, and inoculated, though he considers them to be specifically 
distinct diseases. 

Glanders. — A contagious disease occurring most frequently in 
horses and asses, the exciting cause being the Bacillus mallei. Two 
forms are recognized : (a) Glanders proper, (b) Farcy. (1) Glan- 
ders proper is an acute disease, essentially a necrotic alteration (Unna), 
occurring most frequently on the mucous membrane of the nose and 
upper respiratory tract. Its characteristic lesion is a node or tubercle, 
which is at first spherical, later becomes flattened, then breaks down 
and presents more or less extensive ulcerations which tend to run 
together. The mucous membrane is swollen, is of a purplish or dark- 
red color, and there rs considerable exudate from the ulcerating sur- 
faces. The process may extend to the lungs, the most prominent lesion 
being a catarrhal pneumonia, in which the diseased areas show a 
marked tendency to break down, with the formation of abscesses. An 



2i6 POST-MORTEM EXAMINATIONS 

eruption of papules, which soon become pustular, frequently appears 
upon the face and about the joints. The cervical glands are usually 
much enlarged. A dirty-yellow pasty mass of pus in the gastrocnemii 
is probably due to glanders. Chronic glanders usually occurs in the 
nose and is often mistaken for a chronic coryza. There are frequently 
ulcers about the turbinated bones. ( 2 ) Farcy may be acute or chronic. 
The acute form is of the nature of a phlegmonous inflammation at the 
point of inoculation. The process may be very extensive and lead to 
rapid suppuration of the surrounding parts. Metastasis to the sur- 
rounding tissues is common, accompanied by the formation of ab- 
scesses in the muscles. In chronic farcy localized tumors are found, 
usually in the skin, the subcutaneous tissue, and the muscles. These 
tumors result in abscesses and may form deep ulcers. The disease in 
man has been described as a chronic specific pyaemia, characterized by 
eruptions on the skin and nasal mucous membranes, with frequent 
intramuscular abscesses. 

Gonorrhoeae Infection. — Lesions due to the presence of the 
gonococcus. That organism has been found in the blood, which after 
death may be fluid or semiliquid and tarry-black in color. Manifesta- 
tions of the infection include: (1) Arthritis. — The inflammation is 
acute, periarticular, and extends along the sheaths of the tendons. It is 
a synovitis which rarely becomes purulent. (2) Conjunctivitis. — This 
occurs most frequently in the new-born. It leads to thickening and 
ulceration of the conjunctivae; erosions or entire destruction of the 
cornea may result. The skin of the lids may be destroyed. ( 3 ) Endo- 
carditis. — An acute form of simple or ulcerative endocarditis, from 
which pure cultures of the gonococcus have been made. (4) The results 
of gonorrhoeal infection are periurethral abscess, prostatitis, vaginitis, 
salpingitis, iritis, pericarditis, pleurisy, etc. All these lesions show a 
marked tendency to suppurative change. 

Hydrophobia. — Rabies is a convulsive disease due to the action of 
the toxins of the bacillus of hydrophobia on the higher nervous centres. 
The cerebrospinal system shows congestion of the blood-vessels. There 
are minute hemorrhages, most numerous in the medulla. The mucous 
membrane of the pharynx is congested and not infrequently covered 
with blood-stained mucus. This is true of the larynx, trachea, and 
larger bronchi, also of the lungs, oesophagus, and stomach. Experi- 
ments have shown abundant virus in the spinal cord, brain, and periph- 
eral nerves, but it has not been found in the liver, spleen, or kidneys. 



M1CRO-ORGANISMAL DISEASES 217 

When a dog that is supposed to be mad has bitten a human being, the 
animal should not be at once killed, but permitted to live and kept 
under close observation until it shows unmistakable signs of rabies. 
It should then be killed and its body sent to a competent bacteriologist 
for microscopic study and inoculation experiments on rabbits. While 
the recent so-called rapid method of diagnosing rabies is not abso- 
lutely characteristic of the disease, it affords a most valuable and early 
means of tentative diagnosis, to be confirmed or disproved by subse- 
quent animal inoculation. The method employed is that of Babes, 
van Gehuchten, and Nelis, and is as follows : 1 Several intervertebral 
ganglia or a portion of the bulb are put at once into absolute alcohol, in 
which they are left for twenty-four hours. They are then transferred 
for one hour to a mixture of absolute alcohol and chloroform, next put 
for one hour into pure chloroform, then for one hour into a mixture of 
chloroform and paraffin, and lastly for an hour into pure paraffin. The 
sections are put in the oven for a few minutes, then passed through 
xylol, absolute alcohol, and ninety per cent, alcohol, after which they 
are stained for five minutes in methylene-blue, according to Nissl's for- 
mula, differentiated in ninety per cent, alcohol, dehydrated in absolute 
alcohol, and cleared in essence of cajuput and xylol. Other methods 
of preparing the tissues may be used, as the rapid fixation with ten 
per cent, formalin, subsequent freezing, and staining with hematoxylin 
and eosin. The microscopical changes are chromatolytic and capsular. 
The " rabic tubercle" of Babes consists in the pericellular accumulations 
of the embryonal cells described by Kolesnikoff. The prolongations of 
the cells of the bulbar nuclei are shortened, the nuclei are altered or 
even obliterated, and the nerve-cells are invaded by the embryonal cells 
and small corpuscular elements. Atrophy, invasion, and destruction 
of the nerve-cells of the intervertebral and plexiform ganglia of the 
pneumogastric take place by cells newly formed from the capsule, 
which appear between the cell body and its endothelial capsule, in 
advanced cases the field even resembling an alveolar sarcoma. 

Influenza. — The grippe is an acute, epidemic, contagious disease, 
due to Pfeiffer's bacillus, and characterized by abrupt onset, great 
depression, and many sequelae. The bacillus is found in the nasal and 
bronchial secretions. It is one of the smallest organisms known, non- 



1 Ravenel and McCarthy, Proceedings of the Pathological Society of Phila- 
delphia, 1 901, p. 93. 



2i8 POST-MORTEM EXAMINATIONS 

motile, and stains well with Loffler's methylene-blue. On culture 
media it grows best in the presence of haemoglobin, (i) Lesions of 
the respiratory form are those of an acute inflammation of the mucous 
membrane of the upper respiratory tract and bronchial tubes. Lobular 
pneumonia is common, and is probably due to a mixed infection. 
Pleurisy is more rare, but may lead to empyema. Tuberculosis is apt to 
be exaggerated by an attack of influenza. (2) In the gastro-intestinal 
form the inflammation extends to the mucous membrane of the stom- 
ach and the intestines. It is seldom of a severe type. The spleen is 
usually enlarged in this form. The recent large number of cases of 
appendicitis is attributed by some to the wide-spread prevalence of 
this disorder. (3) In the nervous form mild degrees of meningitis 
and encephalitis are not uncommon. Abscesses of the brain have 
occurred in severe acute cases. In some epidemics accumulations of 
pus in the nasopharynx are exceedingly common. Complications. — 
Acute diffuse nephritis is quite frequent. Endocarditis, pericarditis, 
and thrombosis have been reported. Occasionally purpura is seen and 
also catarrhal conjunctivitis and iritis. In an autopsy on a child dying 
from meningitis following the grippe Dr. Kneass isolated for me the 
influenza bacillus. 

Leprosy. — Leprosy is an infectious disease characterized by the 
formation of a node or nodule, and due to the leprosy bacillus. The 
Bacillus leprce has many points of resemblance to the bacillus of tuber- 
culosis. It, however, stains more readily, is more easily decolorized, 
and is present in far greater numbers in the lesions which it causes. 
( 1 ) The tubercular form starts as a small red spot in the corium, which 
either disappears or gives rise to the formation of inflammatory nodules 
of a brownish-red color, somewhat soft in consistency, and resembling 
a strawberry. The primary lesion is found most frequently in the skin 
of the face and on the surfaces of the knees, the elbows, the hands, 
and the feet. It may also involve the conjunctiva and the mucous 
membrane (particularly the nasal), the cornea, and the larynx. This 
form of the disease is apt to be exceedingly chronic, the surrounding 
tissues showing marked fibroid changes. The tubercles at times 
undergo fatty disintegration and in this way become swollen. (2) In 
the anaesthetic form the leprous process gradually involves the periph- 
eral nerves, first causing a perineuritis, then obliterating them and 
producing marked trophic changes, consisting in necrosis and ulcera- 
tion with extensive loss of substance, as of fingers, toes, and even 



MICRO-ORGANISMAL DISEASES 



219 



limbs. There is great loss of hair and the face often shows marked 
ravages of the disease. Death results not infrequently from laryngeal 
complication or aspiration pneumonia. That leprosy may be cured in 
the sense of the lesions not advancing is now an established fact. Van 
Houtum 1 claims to have cultivated successfully the Bacillus lepra, 
while several investigators have recently given promising reports of the 
discovery of a curative serum. 

Malta Fever. — Mediterranean fever is a chronic disease, resem- 
bling in its clinical course typhoid fever and malaria, occurring most 
frequently in the Mediterranean region, and due to the Micrococcus 
melitensis. It is often followed by swellings of the joints, profuse 
diaphoresis, anaemia, orchitis, and neuralgia. Young and previously 
healthy adults who are unacclimated are most frequently attacked, and 
it is a serious disease in the British garrisons. The micrococcus is 
found in large numbers in the spleen. The visceral changes are those 
common to all infectious diseases with high temperature. The small 
intestine is usually anaemic except in the upper part, where it may be 
intensely congested. The mesenteric glands show little change. The 
spleen is much enlarged and dark in color ; its pulp is soft and friable, 
and sections show an increase in the lymphoid elements. The average 
weight is eighteen ounces. The liver is congested and its surface on 
section is pigmented. The kidneys are usually congested and may be 
slightly hemorrhagic. The agglutinative reaction can be obtained 
with the micrococcus and the blood of a patient affected with Malta 
fever. It should be remembered that this disease occurs in our new 
possessions, and that soldiers on their return home may bring the 
affection with them. 

Measles. — Morbilli or rubeola is a markedly contagious disease, 
attended with a skin eruption and catarrh of the mucous membranes, 
and due to a micro-organism the identity of which is not yet definitely 
settled. This affection, as well as scarlet fever and German measles, 
must be distinguished from Duke's fourth disease, a malady having 
characteristics in common with all three disorders. Lesage, Canon 
and Pielicke, Czajkowski, and others have described organisms as 
causes of the disease. The post-mortem appearances in measles are 
chiefly those of its complications and sequelae. The skin, especially 
about the face, may be swollen and slightly ©edematous, and may show 

1 Journal of Pathology and Bacteriology, September, 1902. 



220 POST-MORTEM EXAMINATIONS 

the remains of the characteristic rash, especially in the hemorrhagic 
type. Desquamation, when present, is in the form of fine branny scales 
The gastro-intestinal mucosa is usually hyperaemic; Peyers patches 
are frequently swollen, sometimes markedly so. The lungs invariably 
show evidence of bronchitis, and almost invariably lesions of broncho- 
pneumonia with areas of collapse; less frequently lobar pneumonia 
may be found. The bronchial glands are invariably swollen. Pleurisy 
is less common. In debilitated infants severe stomatitis, cancrum oris, 
or ulcerative vulvitis may develop. In the middle ear catarrhal inflam- 
mation, which may go on to abscess formation, is not uncommon. Of 
the sequelae tuberculosis is the most important; it is either miliary or a 
caseous pneumonia. Severe forms of conjunctivitis and ulcer of the 
cornea are not uncommon. Nephritis is exceedingly rare. There is 
cloudy swelling of the organs. 

Mumps. — An acute, infectious, contagious disease, characterized 
by a marked cellular infiltration of the parotid glands, which do not 
tend to suppurate or to become fibroid, and frequently complicated 
with metastases to the ovaries and mammary glands in females, and 
the testicles in males, (a) Probably due to a coccus infection, (b) 
Childhood and adolescence. Very young infants and adults are seldom 
attacked. Uncomplicated mumps is rarely fatal. Of the complications 
meningitis, acute mania, endocarditis, gangrene, and optic atrophy are 
the most important. 

Plague. — An acute, infectious, contagious, epidemic disease, due 
to the Bacillus pestis, occurring usually in the far East, but at present 
(1903) widely distributed over the earth's surface, and characterized 
by marked glandular enlargements which tend to suppuration and by 
a general septic condition. The bacillus was discovered by Kitasato 
and Yersin. It is a short rod with rounded ends, and is found in the 
blood, glands, and viscera. Hossack found no buboes in thirty per 
cent, of his cases in Calcutta in 1900. Varieties . — (a) Bubonic, (b) 
Pneumonic, (c) Septic, (d) Intestinal, (e) Meningeal. (/) Car- 
buncular. Lesions : ( 1 ) At the point of inoculation, which usually 
occurs on the lower extremities, there appears a small spot (plague- 
corpuscle) which soon becomes a vesicle and then a pustule. (2) Fol- 
lowing primary inoculation, the inguinal glands become swollen, suc- 
ceeded in order by the axillary, cervical, popliteal, and then any of the 
glands in the body may become affected. The diseased glands swell 
rapidly and are at first tense and firm to the touch, but soon undergo a 



MICRO-ORGANISMAL DISEASES 221 

suppurative change, and in rare cases gangrene ensues. It may be 
stated that it is the periglandular tissue which becomes cedematous and 
undergoes septic inflammation. (3) Carbuncles may develop in the skin 
of the legs, hips, and back. Subcutaneous hemorrhages are very com- 
mon and may also occur in the mucous membranes. (4) The central 
nervous system, especially the brain, is deeply congested. The brain 
substance may become softened and the blood-vessels, especially the 
veins, are engorged. (5) The lungs are deeply congested, especially 
posteriorly., and are at times the primary seat of the disease. (6) The 
pericardium contains an excess of blood-stained fluid. The right 
heart is dilated with black, imperfectly coagulated blood, and the whole 
venous system is engorged. The heart-muscle is pale and somewhat 
softened. (7) The stomach and small intestine contain blood or blood- 
stained fluid. There may be ulceration, but Peyer's patches are not 
affected. The spleen is greatly enlarged in all cases. (8) The dorsum 
of the tongue is coated, but the edges, the tip, and often the median 
raphe remain pink and clean ; sometimes, however, becoming red and 
dry (Hossack). The disease must be distinguished from puerperal 
fever, septicaemia, pyaemia, smallpox, influenza, cerebrospinal menin- 
gitis, diphtheria, erysipelas, measles, gonorrhoea, syphilis, mumps, ma- 
laria, scrofulous glands, Hodgkin's disease, etc. In a recent case of a 
Chinaman suspected of having the plague, the writer found almost 
complete occlusion of the prepuce, with a discharge containing the 
gonococcus, and in the suppurating bubo a fat diplo-bacillus which did 
not stain by Gram's method. 

Relapsing Fever. — An acute, epidemic, contagious disease, not 
found at the present time in America unless imported, occurring in the 
same class of persons as typhus fever, giving rise to a fever which lasts 
from five to seven days, followed by relapses, and due to the Spiro- 
chete? of Obermeier, which are found in the blood only during the 
paroxysms of fever. Due to a specific, motile organism, which is 
rarely discovered post mortem. No characteristic or constant lesions 
are found after death. The following are sometimes present. ( 1 ) If 
death occurs during the paroxysm, the spleen is large and soft; the 
pulp is purple. The follicles are enlarged and often obliterated, though 
they may be gray or whitish yellow in color. Infarcts are not uncom- 
mon. (2) The heart is flabby, of a pale dirty-gray color, and very 
friable. (3) The liver is more enlarged in this than in any other 
infectious fever. Its color is uniform gray-red. Fatty degeneration 



222 POST-MORTEM EXAMINATIONS 

may be marked. (4) The kidneys may retain their normal weight. 
The renal parenchyma is soft and flabby; the cortical substance is 
increased and shows cloudy swelling. Hemorrhagic spots or lines 
radiating to the pyramids are often observed. (5) The lungs may be 
the seat of pneumonic infiltration, bronchitis, or bronchiectasis. (6) 
Hyperplasia of the bone marrow has been found. Complications. — 
(a) Pneumonia is frequent, (b) Rupture of the spleen, (c) Nephri- 
tis and hematuria, (d) Ophthalmia in certain epidemics, (e) Abor- 
tion usually takes place. (Osier.) 

Rheumatic Fever. — (a) Follows exposure to cold and wet. (b) 
Usually regarded as a coccus infection, though a bacillus has also been 
described as the etiologic factor. (1) The affected joints are swollen, 
tense to the touch, and somewhat hyperemia The fluid in the joint is 
turbid, and contains albumin, leucocytes, and a few flakes of fibrin, but 
rarely pus. There may be slight erosion of the cartilages. (2) Endo- 
carditis occurs in about sixty per cent, of all cases. The verrucose 
variety is most common. The mitral valve is most frequently involved. 
(3) Pericarditis may occur, with or without endocarditis. It may be 
fibrinous, serofibrinous, or, in children, purulent. (4) Myocarditis 
occurs most frequently in association with endopericarditis. It leads 
to weakening and dilatation of the heart-muscle, and is the most com- 
mon cause of sudden death in rheumatic fever. (5) Pleurisy and 
pneumonia occur in about ten per cent, of all cases. (6) Rheumatic 
nodules, varying in size from a small shot to a large pea, are found 
on the fingers, hands, and wrists. They may also occur about the 
elbows, knees, spines of the vertebrae, and scapulae. (7) Meningitis 
is extremely rare. (8) Purpura may be present. 

Rheumatism, Chronic. — (1) The synovial membranes are in- 
jected. There is usually not much effusion. The capsules, ligaments, 
and sheaths of the tendons are thickened. There may be erosion of the 
cartilages. As a result of these changes, the joints are often deformed 
and ankylosis may occur. (2) Muscular atrophy, especially about the 
joints, frequently follows. (3) Valvular heart-lesions, due to sclerotic 
changes, are of common occurrence. 

Rubella (Rotheln, German Measles). — This disease is rarely 
fatal in uncomplicated cases. There is no distinctive lesion other than 
the rash, which may fade entirely after death. 

Scarlet Fever. — (a) The majority of cases occur before the tenth 
year, (b) Infants and adults are usually exempt, (c) Cocci are fre- 



MICRO-ORGANISMAL DISEASES 



223 



quently found in the throat-lesions and in the blood. Class, of Chi- 
cago, claims to have isolated a specific coccus, which has also been 
described by Baginsky. (1) Rigor mortis is usually well marked. 
Decomposition may set in early and develops with exceptional rapidity, 
cadaveric lividity usually appearing before death. (2) The blood is 
dark in color, thin, and coagulates imperfectly. The vessel-walls are 
usually stained. (3) Except in the hemorrhagic form the skin after 
death rarely shows a trace of the rash. (4) In the throat follicular 
tonsillitis, diphtheritic membrane, or suppuration may be present. 
Punctate hemorrhages, especially about the mouth, are always ob- 
served. (5) Catarrhal inflammation of the gastro-intestinal mucous 
membrane is not uncommon. The follicles of the small intestines are 
swollen, red, and may even be hemorrhagic. (6) In severe cases an 
intense lymphadenitis, with much inflammatory cedema, is found in 
the neck. This may lead to suppuration or even gangrene, and in rare 
cases to ulceration of the carotid artery and fatal hemorrhage. (7) 
The kidney lesions are most important. Acute diffuse nephritis is 
present in a majority of cases. It is frequently of the glomerular 
type and may be hemorrhagic. This lesion is not infrequently fol- 
lowed by the changes observed in chronic parenchymatous nephritis. 

(8) Endocarditis, which may be either simple or malignant, is not 
infrequent. Pericarditis and myocardial changes are less common. 

(9) The spleen is often enlarged, and shows the changes which char- 
acterize acute splenic tumor. (10) Hemorrhages into the subserous 
tissues beneath the pericardium, endocardium, and pleura are quite 
frequent. There is more or less cloudy swelling of all the organs. 
Complications. — (a) The most important is nephritis. The urine is 
small in quantity, of a high specific gravity, cloudy, and of a dark 
blood-color. It contains large amounts of albumin, free blood, and 
epithelial cells, with hyaline and epithelial tube-casts. (Edema may 
be slight or marked; in a few cases cedema of the glottis has caused 
sudden death. ( b ) Heart complications are next in importance. There 
may be endocarditis, pericarditis, or myocarditis, (c) Catarrhal pneu- 
monia, more rarely croupous pneumonia or pleurisy, may occur, (d) 
Involvement of the middle ear may lead to thrombosis of the lateral 
sinus, meningitis, abscess of the brain, or necrosis en masse of the 
middle ear. (e) Adenitis may result. The glands of the neck are those 
most frequently involved. There may be great destruction and loss of 
tissue, (f) Arthritis of a rheumatic type or more closely resembling 



224 



POST-MORTEM EXAMINATIONS 



the gonorrhceal variety may be found. In the latter affection only one 
joint is involved and suppuration may supervene. The toxin seems to 
act especially on the epithelial cells. In one of my cases death occurred 
in convulsions twenty- four hours after the onset of vomiting and with- 
out the appearance of any rash. The diagnosis was confirmed by a 
sister being attacked with the disease later on. 

Scleroderma (Hide-bound Skin). — (i) Circumscribed Form. 
— On the skin are found patches varying in size and of a waxy or dead- 
white appearance. They are brawny, hard, and inelastic. (2) Dif- 
fuse Form. — This form usually occurs in the extremities or on the face. 
Gradually a diffuse brawny induration develops. The skin becomes 
firm, hard, and so closely united to the subcutaneous tissue that it can- 
not be picked up or pinched. The color may be natural. The skin is 
commonly glossy, drier than normal, and unusually smooth. 

Smallpox. — (a) Overcrowding, (b) Improper food, (c) Sea- 
son, fall or winter, (d) Streptococci are found in the characteristic 
lesions. Councilman 1 has announced the discovery of a protozoon. 

( 1 ) The characteristic lesion of smallpox is a rash. On the skin may 
be seen papules, umbilicated vesicles, pustules, and crusts. A shot-like 
feel of the papules upon the forehead and wrist is quite characteristic. 

(2) The rash may also be found upon the mucous membranes from 
the mouth to the rectum, but on account of the moisture the pocks are 
not quite so characteristic in these situations as upon the skin. In some 
cases there is deep ulceration, especially in the larynx, which may be 
followed by necrosis of the cartilages. ( 3.) Swelling of Peyer's patches 
is not uncommon. (4) In the hemorrhagic form of smallpox extrava- 
sations of blood are found on the serous and mucous surfaces, in the 
parenchyma of the organs, in the connective tissue, and about the 
nerve-sheaths. They have also been observed in the bone-marrow and 
in the muscles. (5) As a rule, the spleen is markedly enlarged, but it 
may be small, very dark, and firm. The liver shows evidences of 
parenchymatous inflammation. (6) The heart is flabby and pale. 
The myocardium shows cloudy swelling and fatty degeneration. It is 
often dark brown in color and may be firm to the touch. The cavities 
contain little or no clotted blood, and the arterial trunks are nearlv 



1 See Ziegler's General Pathology, translation by Cattell, 1895, p. 39 : " It is 
not impossible that other infectious diseases — for instance, smallpox — are caused by 
parasites that belong among the protozoa." 



MICRO-ORGANISMAL DISEASES 



225 



empty. (7) Lesions of the kidney are not common. It may show 
cloudy swelling and areas of focal necrosis, or the pelvis may be 
blocked with dark clots which sometimes extend into the ureters. (8) 
Absence of the scar resulting from vaccination is very often noted. 
(9) The epidermis of the hands and feet may be shed entire. The 
skin is sometimes plum-colored. (10) The face may be swollen. In 
black smallpox there may be found hemorrhages in all the numerous 
membranes and in joints. The cornea may be sunken. Complications. — 
(a) Bronchopneumonia is almost invariably present in fatal cases; 
lobar pneumonia and pleurisy less commonly, (b) Albuminuria is 
frequent, but true nephritis rare, (c) Purulent changes in the arteries, 
bones, conjunctiva, and middle ear are common, (d) Ulcerative laryn- 
gitis with oedema sometimes causes death, (e) Myocarditis, endocar- 
ditis, and pericarditis are comparatively common. At the postmortem 
the odor is so characteristic that the disease may be recognized by this 
means alone. The physician should always vaccinate himself both be- 
fore and after making an autopsy on a smallpox case. 

Sprue (Psilosis). — A chronic remittent inflammation of the 
whole or part of the mucous membrane of the alimentary canal, occur- 
ring principally in persons residing, or who have resided, in tropical 
or subtropical climates. Apparently nothing is known of its origin. 
At postmortem the thoracic organs, the abdominal viscera, and the 
tissues generally are found to be much wasted, giving the body a mum- 
mified appearance. The bowel is exceedingly thin, and on opening it 
a thick layer of dirty viscid gray, tenacious mucus is seen. On re- 
moving this, areas of congestion, ulceration, pigmentation, or thicken- 
ing may be found. The mesenteric glands are generally enlarged. 

Syphilis. — Lustgarten and van Niessen have described specific or- 
ganisms, neither of which has been definitely accepted. Classification. — 
I. Acquired Form. — (a) Primary, (&) Secondary, (c) Intermediate 
period, (d) Tertiary. II. Hereditary Form. — (a) Primary, (b) 
Secondary. The following lesions should be looked for in making a 
postmortem: (1) The initial lesion or its scar. (2) Lymphatic en- 
largement, especially of the groin, neck, and elbow. (3) Various skin 
lesions and thinness of the hair. (4) Mucous patches. (5) Onychia 
and dactylitis. (6) Gumma in the viscera, skin, subcutaneous tissues, 
muscles, etc. (7) Parotitis. (8) The bones for periostitis or osteo- 
myelitis. (9) The eye for iritis or choroiditis. (10) The bowels for 
stricture, especially the rectum. (11) The nervous system for tabes, 

15 



22 6 POST-MORTEM EXAMINATIONS 

dementia paralytica, and other forms of sclerosis. I. The lesions found 
in the primary stage are : ( i ) The chancre. This begins as a small 
red papule, usually situated at the junction of the skin and mucous 
membrane. It gradually enlarges and breaks in the centre, leaving a 
small ulcer with indurated edges and base. (2) The neighboring lym- 
phatic glands are enlarged and hard. II. Secondary Stage. — ( 1 ) Cuta- 
neous eruptions of all forms. As a rule, the syphilide is polymorphous, 
varying in form from an erythema to a pustular eruption. It is sym- 
metrically distributed and of a reddish-brown or copper color. It 
appears most frequently on the chest, abdomen, and flexor surfaces of 
the arms. (2) The mucous patch is a softened and macerated epithe- 
lium, and appears on the mucous membrane or on the moist regions 
of the skin. It is most frequently found in the mouth, in the throat, 
and about the anus. The mucous patch is irregularly shaped, non- 
inflammatory, and does not discharge pus. (3) The hair of the scalp 
is decidedly thin. (4) Ulcers may be seen on the tonsils and larynx. 
(5) There may be warts about the vulva and anus. (6) Iritis is com- 
mon; retinitis rare. (7) The finger-nails may be diseased, forming 
dry or moist onychia. (8) Periostitis may be present. III. In the 
intermediate stage there are but few lesions: (1) Gumma of the tes- 
ticles and (2) choroiditis are the only ones found. IV. Tertiary 
Stage. — ( 1 ) The late syphilides show a tendency to ulcerate and 
destroy the deeper layers of the skin, leaving scars. Rupia may de- 
velop. (2) The gummata are the characteristic lesions, and may be 
hard or soft. The former develop in the internal organs and in the 
mucous membranes. They most frequently terminate in cicatrization, 
forming stellate scars which often cause marked deformities. Soft 
gummata are found in bones, skin, etc. They tend to break down and 
ulcerate, leaving chronic indolent, often serpiginous, sores. ( 3 ) When 
there has been prolonged suppuration, amyloid degeneration of the 
liver, spleen, and kidneys often occurs. This is especially true with 
regard to rectal syphilis in women. (4) Circulatory System. — The 
heart frequently shows sclerotic changes of the valves, especially about 
the aorta. ( 5 ) The blood-vessels present arteriosclerosis or atheroma- 
tous changes. (6) In the central nervous system scleroses of the 
brain and cord and gummata are common. V. Congenital Syphilis. — 
(1) At birth the infant is usually apparently healthy, but it may 
present well-marked lesions. (2) There is wasting, and pemphigus 
is noticed on the hands and feet. (3) The lips may be ulcerated and 



MICRO-ORGANISMAL DISEASES 



227 



the mouth and anus fissured. (4) There is inflammation of the nasal 
mucous membrane; hyperemia with papillary infiltration is present 
and necrosis of the bone may occur. (5) The spleen and liver are 
enlarged. (6) The lungs may present the lesions of white pneumonia 
or miliary gummata. (7) The long bones usually show characteristic 
changes, and the epiphysis may be separated. (8) Later the child 
looks prematurely old. The teeth are wedge-shaped and the cutting 
edges notched (Hutchinson's teeth). (9) Eye lesions may be seen as 
interstitial keratitis. (10) Dactylitis is not uncommon. 

Syphilis of the Brain and Cord. — (1) Gummata are usually mul- 
tiple, varying in size from a pea to a walnut. In the cerebrum they 
occur along the sulci. Heubner describes two forms. In the first 
variety they are grayish or grayish red in color, soft, and not sharply 
defined. On section they are moist and exude a small amount of juice. 
In the second form they are quite hard and dry. Their outline is dis- 
tinct. On section they may be cheesy and look not unlike tubercular 
growths. An enarteritis around them exists and causes softening. 

(2) Gummatous arteritis and sclerosis of both arteries and nerve tissue 
may exist. (3) There may be softening due to obstruction of the 
blood-vessels. Recently in Philadelphia a man was condemned to 
death for killing a person in cold blood. A commission of experts pro- 
nounced him sane. The man committed suicide by hanging, and I 
found at the postmortem numerous gummata of the brain, situated 
especially in the right temporal and frontal regions. 

Syphilis of the Circulatory System. — (1) Gummata are rare. (2) 
Fibrosis of the heart-muscle is common. (3) Sclerosis of the valve is 
frequent. (4) Arteriosclerosis, aneurism, and endarteritis obliterans 
are common. 

Syphilis of the G astro-Intestinal Tract. — (1) The oesophagus is 
rarely affected. Ulceration or stenosis may be present. (2) Ulcers, 
phlegmonous inflammations, or abscesses may be found in the pharynx. 

(3) Ulcers may occur in the small intestine and caecum. (4) The rec- 
tum is not infrequentlv the seat of cicatricial contraction. This lesion 
is most frequently seen in women. The lesions that syphilis produces 
in the gastro-intestinal tract are (a) chancre, (b) ulcers, (c) localized 
fibrous patches, (d) gummata, (e) miliary nodules, (f) condyloma- 
tous masses. 

Syphilis of the Kidneys. — (1) Gummata are not infrequent. (2) 
Acute syphilitic nephritis may occur. (3) Chronic interstitial nephri- 



22 8 POST-MORTEM EXAMINATIONS 

tis is more common. This is a localized nephritis caused by the result- 
ant shrinking and marked irregularity of the surface of the kidney. 
It is sometimes hard to distinguish it from old infarcts, but the change 
in color, which in syphilis is gray, in infarcts is brown, is a pretty 
certain point of differentiation. 

Syphilis of the Larynx. — (a) Congenital, (b) Acquired, which 
may be secondary or tertiary. ( i ) In the secondary form there is 
erythema, with symmetrical, superficial, whitish ulcers on the cords or 
ventricular bands. (2) Mucous patches are occasionally seen. (3) In 
the tertiary form true gummata may appear towards the base of the 
epiglottis. These break down, producing deep flask-shaped ulcera- 
tions, which may heal by connective tissue that shrinks and produces 
stenosis. (4) Islands of connective tissue commonly appear between 
the cicatrices and form inflammatory excrescences. (5) The neigh- 
boring cartilages may show necrotic changes. (6) A fatal termination 
may result from perforation of an artery. 

Syphilis of the Liver. — (1) In diffuse syphilitic hepatitis there is 
marked fibrous change. The organ is hard, firm, and resistant. The 
disease usually begins with a perihepatitis, which frequently causes 
adhesions to the surrounding structures. With contraction of the 
fibrous tissue great deformities of the liver become manifest. Capillary 
bile ducts may be present in abundance in the cirrhosed portion. (2) 
The smaller gummata are pale-grayish nodules, the larger ones pale 
yellowish in color. Usually they are multiple (miliary). Although 
they may be present in any part of the organ, the most common situa- 
tion is at the junction of the right and left lobes. Great deformity 
results from healing and contraction. 

Syphilis of the Lung. — (1) In white pneumonia of the foetus the 
affected lung is heavy and airless. On section it presents a grayish- 
white appearance (white hepatization). (2) Hereditary gummata 
are small in size, grayish in color, firm in consistence, and more or less 
symmetrically distributed throughout the lung. (3) Acquired gum- 
mata vary in size from a pea to a goose's egg. They are grayish yellow 
in color and are embedded in connective tissue. The parts around them 
are hard and brawny and of a glossy lustre. These gummata may 
break down and form cavities. This condition is called syphilitic 
phthisis. (4) There may be a fibrous interstitial pneumonia in which 
the lesions are hard, large, and pale or dark grayish red in color. The 
middle of the right lung or either apex is the part most frequently 



MICRO-ORGANISMAL DISEASES 



229 



involved. (5) The pleura is thickened. (6) Endocarditis may extend 
to the hepatic artery and portal vein. 

Syphilis of the Testes. — (1) Gummatous growths usually involve 
the epididymis, which becomes a hard mass, from the size of a bean to 
that of a walnut. It affects the head more commonly than the body of 
the epididymis. (2) In interstitial orchitis the progress of the disease 
is slow. The organ is larger than normal and distinctly harder to the 
touch. The overlying skin is not adherent and there is no tendency to 
suppuration. 

Tetanus. — The bacillus of tetanus is a slender rod usually grow- 
ing in long threads. It is motile, grows on ordinary media at ordinary 
temperatures, and is anaerobic. It stains readily, but does not retain 
the stain very well. (1) The bacilli . develop at the site of the wound, 
which is usually of a penetrating character, and do not invade the blood 
or organs, except very rarely late in the course of the disease. (2) No 
characteristic lesions have been found. (3) The condition of the 
wound depends upon the kind and extent of the injury. (4) The 
central nervous system shows congestion, with perivascular exudations 
and granular change in the nerve-cells. Some investigators have found 
swelling and areas of disintegration in the gray matter of the cord ; 
with exudation of a finely granular material and disintegrated blood. 
(5) In tetanus neonatorum the umbilicus may be inflamed. (6) The 
rectus muscle has been found ruptured as the result of a spasm. (7) 
Death may occur from heart-failure or asphyxia. 

Thrush. — This disease is due to the O'idiiim albicans, or thrush 
fungus. Parts affected: (1) The mouth, tongue, cheeks, etc., are 
more or less densely covered with minute, slightly raised, white spots, 
which are quite firm and adherent to the mucous membrane. When 
scraped off and examined microscopically, the characteristic fungus is 
seen. (2) Occasionally the fungus invades the oesophagus and grows 
to such an extent as seriously to obstruct its lumen. 

Tuberculosis. — Any morbid lesion produced by or through the 
agency of the tubercle bacillus, which is a rod-shaped micro-organism, 
measuring in length about one-half the diameter of a red corpuscle 
and in width two-tenths of a micron. It is bent upon itself, grows 
best on agar containing glycerin, stains with difficulty, but retains the 
stain tenaciously. The best method of staining is by carbol-fuchsin 
and Gabbett's solution. When stained it often has a beaded appear- 
ance. It is morphologically similar to the bacillus of leprosy and the 



230 



POST-MORTEM EXAMINATIONS 



smegma bacillus. Tuberculous lesions are: I. Acute. — (a) Miliary 
tuberculosis, (b) Caseous pneumonia or phthisis florida. (c) Tuber- 
culous ulcerations. II. Chronic. — (a) Diffuse tuberculosis, ulcerative 
phthisis, or caseous tuberculosis, (b) Fibroid phthisis, (c) Cold 
abscesses. III. Modes of Invasion. — (a) Aerogenous. (b) Lympho- 
genous, (c) Hematogenous. IV. Characteristic Lesions of Tubercu- 
losis. — (a) Miliary tubercle, (b) Caseation, (c) Cold abscesses. 
(d) Ulceration. Characteristics of Tuberctrfous Lesions. — (i) Miliary 
tubercle is a small nodule about the size of a millet-seed, grayish white 
in color, semi-translucent, raised above the surface, and primarily ad- 
herent to the surrounding structures. (2) In caseation or diffuse 
tuberculosis two or more miliary tubercles agglutinate, isolating the 
intervening healthy tissue and cutting off its blood-supply. The 
necrosed area loses symmetry of shape and arrangement and undergoes 
fatty degeneration. The area is yellowish in color, soft or firm in con- 
sistence, and is surrounded by an inflammatory zone. There is an 
almost complete absence of blood-vessels. (3) Cold abscess is most 
frequently found in association with tuberculosis of the vertebras. It 
is frequently seen as a " psoas" abscess. The capsule of this abscess 
is more or less imperfect. It does not present the ordinary charac- 
teristics of a pyogenic membrane, the limiting wall being composed 
mainly of broken-down tuberculous tissue with more or less perfectly 
formed tubercles. The contents of the abscess are pale and of a some- 
what watery consistence, composed mainly of broken-down cells, fatty 
debris, and water. Bacteriologically the contents of the abscess are 
usually sterile. V. Distribution of Tubercles in the Body. — (a) The 
lungs are most commonly affected. In two hundred and seventy-five 
cases out of a thousand autopsies, the lungs were, with two or three 
exceptions, involved in all. Other organs were affected as follows : 
(b) Intestines in sixty-five cases, (c) peritoneum in thirty-six, (d) 
kidneys in thirty- two, (e) brain in thirty-one, (/) spleen in twenty- 
three, (g) generative organs in twenty, (h) liver in twelve, (i) peri- 
cardium in seven, and (/) heart in four. (Osier.) VI. Fate of Tuber- 
culous Lesions. — Tuberculous lesions may terminate: (a) In resolu- 
tion, which is rare, (b) In fibroid changes. This sometimes occurs 
in the small intestine and may cause stenosis, (c) In caseation or sup- 
puration, (d) In calcification. (1) Resolution sometimes takes place 
when the area of tuberculosis is small, the blood-supply good, and the 
patient under favorable conditions, especially when leading an out-door 



MICRO-ORGANISMAL DISEASES 23 1 

existence. (2) In healing by fibroid change the area affected is first 
encapsulated and then by gradual pressure and absorption the affected 
area is removed, leaving a scar. (3) Caseation is by far the most 
common result of all tuberculous lesions. The process has been already 
described. Suppuration in tuberculous lesions is the result of the intro- 
duction of pyogenic organisms. (4) Calcification is the most fortunate 
ending of the tuberculous process, and it is estimated by careful ob- 
servers that seventy-five per cent, of all persons who die after the age 
of forty years show this form of tuberculosis in their lungs or pul- 
monary glands. 

Tuberculosis of the Alimentary Tract. — This form may be: (a) 
Primary in the mucous membranes, (b) Secondary to disease of the 
lungs or eating infected food, (c) It occurs rarely through extension 
from the peritoneum. I. Mouth. — (1) Primary tuberculosis, which 
is usually miliary. The tonsils are more often affected primarily than 
was formerly supposed. (2) Secondary to tuberculosis of the face, 
larynx, or lung. It may attack the tongue or cheeks and be miliary 
or caseous. II. (Esophagus. — (1) Primary tuberculosis is very rare. 
(2) Secondary tuberculosis through extension from the lungs or larynx 
is comparatively common. ( 3 ) The lesions may be miliary, caseous, or 
ulcerative. III. Stomach. — Tuberculosis of the stomach is compara- 
tively rare ; Orth never saw a case. IV. Intestines. — The lesions occur 
in the ileum, caecum, colon, and rectum. The most frequent seat is 
in the ileum, just above the ileocecal valve, as it is here that stasis of 
the intestinal contents occurs and a favorable opportunity is given for 
the growth of the tubercle bacillus. ( 1 ) The large bowel is less fre- 
quently involved than the small bowel. (2) Small, firm, gray nodules 
develop, which soon soften and become yellow in the centre. If cut 
into at this stage, pus does not exude as in an ordinary abscess, but a 
thick caseous material may be pressed out. The mucous membrane 
over these nodules finally breaks down and the cheesy material is 
erupted. There remains an ulcer with swollen cheesy base and edges 
(primary tuberculous ulcer of Rokitansky), which soon combines with 
others and enlarges irregularly (secondary tuberculous ulcer of Roki- 
tansky). Miliary tubercles in the form of small gray nodules now 
appear at the base and edges of the ulcer and its immediate vicinity. 
Through the caseation of these, the ulcer enlarges both downward 
and laterally. The round ulcer becomes a long one, with its longer 
axis usually at right angles to the long axis of the intestine; it may 



2^2 



POST-MORTEM EXAMINATIONS 



extend around the bowel. Hemorrhages may occur, particularly at 
the edges. The submucosa and muscularis are usually involved, and 
colonies of young tubercles may be scattered over the serous mem- 
brane. Perforation is rare. Gangrene may occur in a very rapidly 
developing ulcer. Healing sometimes takes place. (3) There may 
be solitary or multiple areas of cicatricial tissue. (4) Fistula in ano 
is quite common. V. ( 1 ) The liver is constantly involved in general 
tuberculosis. It is pale in color, often fatty, and presenting miliary 
tubercles or caseous masses which may break down into numerous 
small abscesses, especially about the smaller bile-ducts. (2) There 
may be a slight increase in the connective tissues, leading to tubercular 
cirrhosis. 

Tuberculosis of the Brain and Cord. — (a) Acute miliary infection. 
(b) Chronic meningo-encephalitis. (c) Solitary tubercles. I. Acute 
Miliary Tuberculosis. — (1) This is usually secondary to tuberculosis 
of the lungs, bronchial glands, or bones. (2) Miliary tubercles occur 
most frequently in the pia and arachnoid of the cerebellum, next in 
the cerebrum, then in the pons. They follow the direction of the blood- 
vessels. They are apt to lead to obliteration of the vessels and thus 
cause softening and necrotic changes. Serous, seropurulent, or sero- 
fibrinous exudate is also present. (3) This acute process may result 
in acute inflammation of the meninges, principally the pia and arach- 
noid. It is spoken of usually as acute hydrocephalus. This is most 
pronounced towards the base of the brain and occurs most frequently 
in children. I have found tubercle bacilli in fluid removed by Quincke's 
lumbar puncture. II. Chronic Meningo-Encephalitis. — The mem- 
branes at the base of the brain are most often involved, next in fre- 
quency the optic chiasm, the Sylvian fissure, and the interpeduncular 
space. The membranes are thickened, firmly adherent, and covered 
with a fibrinous, purulent exudate. The convolutions are flattened 
and the sulci obliterated. The cerebral substance is more or less 
cedematous. The lateral ventricles are dilated and contain a turbid 
fluid. III. Tuberculous Tumors of the Brain. — (1) Solitary tubercles 
are found most usually about the cerebellum. As a rule, they are 
attached to the meninges, often to the pia mater. (2) Cerebral soften- 
ing from pressure is not uncommon. The tubercles vary in size from 
a pea to a small orange. They are grayish yellow in color, caseous, and 
usually firm and hard, but the centre may be semi-fluid. They may 
be surrounded by submiliary tubercles, but are, as a rule, surrounded 
by a soft translucent tissue. (3) They may calcify. 



MICRO-ORGANISMAL DISEASES 



233 



Tuberculosis of the Circulatory System. — (1) Primary tubercu- 
losis of the larger vessels is unknown ; secondary lesions are not infre- 
quently found if carefully searched for. (2) In the lungs, brain, and 
other organs the smaller arteries are usually involved in acute infiltra- 
tion which leads to thrombosis. (3) Tubercles may develop in the 
walls of the vessels, particularly the muscularis, and undergo softening, 
which may result in hemorrhage or a wide-spread distribution of the 
tuberculous infection. 

Tuberculosis of the Genito-Urinary System. — (a) Most common 
in males, (b) Age from twenty to forty years. I. The Kidneys. — 
( 1 ) These organs are frequently the seat of an acute miliary infection, 
which may be primary or secondary. The disease is most marked in 
the cortex. It may be limited to the areas supplied by a single blood- 
vessel. Necrosis and caseation rapidly follow. The miliary tuber- 
cles may be seen in a row in the direction of the vasa interlobularia. 
One or both organs may be affected, but at autopsy both are found to 
be enlarged. (2) Not infrequently one kidney may be completely 
destroyed and converted into a series of cysts ; these contain a cheesy 
substance, and lime salts may be deposited in their walls. This is a 
chronic form of the disease and frequently starts at the apices of the 
pyramids. ( 3 ) The walls of the pelvis may be thickened and cheesy, and 
the mucous membrane converted into a necrotic ulcerating mass. The 
ureters are usually thickened, caseous, or ulcerated. II. The Blad- 
der. — Tuberculosis here is most common in men. ( 1 ) Infection of this 
organ is nearly always secondary to infection elsewhere, particularly 
in the pelvis of the kidney. The bladder is small, shrunken, thick- 
ened, and surrounded by sclerosed tissue. Ulcer formation is most 
common. It is lenticular in shape and is surrounded with red mucous 
membrane. Its seat of predilection is the trigone and fundus. Minute 
gray tubercles may be seen. In advanced cases ulcers are found. (2) 
To find tubercle bacilli in the urine centrifugation should be employed, 
and the precipitate stained in the usual manner for showing these 
organisms. Care must be taken not to get the smegma bacillus ; it is, 
therefore, advisable that the urine be collected with the strictest pre- 
cautions. III. The Testes. — Infection may occur before the second 
year. It may be secondary to peritoneal tuberculosis. At times the 
greater part of the testis is destroyed, its stroma being replaced by a 
softened or still firm caseous deposit, which may be softened in the 
centre. IV. Tuberculosis of the ureters is very rare. V. Salpingitis. — 



234 POST-MORTEM EXAMINATIONS 

The oviducts are enlarged, the walls thickened and infiltrated, and the 
contents cheesy. It is usually bilateral. 

Tuberculosis of the Larynx. — The lesions may be primary or sec- 
ondary, usually the latter. The lesions found are : ( i ) Miliary tuber- 
culosis. (2) Diffuse tuberculosis. (3) Ulceration. In early cases 
the epithelium is intact, the tubercle starting in the mucosa or sub- 
mucosa. 

Tuberculosis of the Lung. — I. Acute. — (a) Miliary tuberculosis. 
(b) Phthisis florida, showing itself as bronchopneumonic tubercles, 
as lobar-pneumonic tubercles, or as a combination of both. II. 
Chronic. — (a) Ulcerative phthisis, (b) Fibroid phthisis. I. Acute. — 

( 1 ) In acute miliary tuberculosis the lesions are usually present in both 
lungs. They are frequently so small and transparent that they may be 
overlooked on macroscopic examination. At other times they are 
aggregated in localized spots or even become diffuse. In the latter case 
the lung is increased in size, is firm in consistence, in color is a darker 
shade of red, is heavier, and crepitates. The pulmonary vessels should 
be opened with the scissors, and seldom in the pulmonary arteries but 
often in the veins miliary tubercles can be seen, the infection having 
been brought through the circulation. Such tubercles may, however, 
be localized near an old caseous mass, the lymphatic system then 
being the transmitter. Local spots of emphysema are seen if the 
condition is not very acute. The tubercles may be peribronchial, peri- 
vascular, or in the parenchyma. There is a chronic miliary tubercu- 
losis which presents a combination of lesions of both acute miliary 
tuberculosis and phthisis and is the connecting link between the two. 

(2) Phthisis florida, or acute phthisis with formation of cavities, pre- 
sents a varied appearance. One lobe only, or more or less of the 
whole lung, may be affected. The organ is heavy; the implicated 
portions do not collapse and are firm and airless. The pleura is 
covered with a thin exudate. On section the condition may resemble 
red or gray hepatization or an intermediate stage between them. In 
other instances the lung presents a mottled appearance, some areas 
being intensely congested, others exhibiting a characteristic pale-gray 
gelatinous exudate, others caseous degeneration and not infrequently 
cavity formation. Recently affected areas of pulmonary tissue with 
croupous pneumonia are often seen. II. Chronic. — (1) In ulcerative 
tuberculosis apical involvement in relation to implication at the base 
exists in the proportion of five hundred to one, according to Kidd. 



MICRO-ORGANISMAL DISEASES 235 

There are varied lesions. First, there are caseous nodules, which are 
grayish, white, or yellow in color. Second, cavities may exist, which, 
if the case is acute, have walls made up of soft caseous masses. In 
the more chronic cases these walls are replaced by pyogenic membranes 
of greater or less density, at times covered with granulations. Fre- 
quently trabecular are seen in the walls; these are the blood-vessels, 
branches of the lung artery, which have resisted the tuberculous pro- 
cess. The arteries sometimes become aneurismal. Their rupture may 
be followed by hemorrhage severe enough to cause death. Frequently 
they are contracted and empty, due to a previous endarteritis or throm- 
bosis. Third, pneumonic areas and evidences of chronic bronchitis are 
seen. Fourth, some thickening of the pleura is constant. This may 
be merely an acutely inflamed area rubbing against a corresponding 
area on the parietal pleura or it may be tightly adherent to it. Not 
infrequently perforation causes a pyopneumothorax. Fifth, enlarged 
bronchial glands are discovered which are caseous and often pig- 
mented. Lastly, the bronchi are thickened and the lumina of the 
smaller ones frequently obliterated. The larger tubes show caseous 
deposits in the submucous and- fibrous coats. (2) In fibroid phthisis 
the organ is permeated with interstitial overgrowth. In some cases 
the interstitial change is most prominent; in others the tuberculous 
process is slightly more marked. The unaffected portions of the lung 
are largely emphysematous and pigmentation is considerable. The 
right ventricle and sometimes the whole heart are hypertrophied. 

Tuberculosis of the Lymphatic Glands. — (1) Location, most fre- 
quent in the cervical chain. (2) Extension opposite that of the lym- 
phatic stream. (Treves.) I. Chronic Form. — (1) Hard. (2) 
Non-adherent. (3) Yellowish white in color. (4) Little tendency 
to break down and suppurate. (5) Tendency to be localized. (6) 
Overgrowth of connective tissue considerable. In tabes Virchow 
compared them to a sectioned potato. II. Less Chronic Form. — (1) 
Not as dense. (2) Tendency to become adherent. (3) Gray or 
grayish white in color. (4) Tendency to liquefy and suppurate. 
(5) Connective tissue less in amount. (6) Tubercle bacilli more abun- 
dant. When tuberculous lymphatic glands are associated with phthisis, 
they are sometimes found to have opened into a bronchus and caused 
the disease. This is particularly common in children, and especially 
when the middle and lower lobes are involved. 



236 POST-MORTEM EXAMINATIONS 

Tuberculosis of the Mammary Gland. — (a) Female sex. (b) 
Strumous temperament, (c) Age from the fortieth to the sixtieth 
year. The seat of predilection is the gland duct. (1) Induration is 
at first small and very slowly increases in size. (2) The nipple may 
be retracted. (3) The skin over the gland becomes riddled with 
sinuses with indurated edges. (4) Associated with lymphatic en- 
largement, tuberculosis of bone, or other tubercular involvement near 
the gland. 

Tuberculosis of the Peritoneum. — I. Miliary Form. — (1) On 
opening the abdominal cavity the serous membranes seem to be cov- 
ered to a greater or less extent with miliary tubercles, which are 
present in the mesentery and the omentum also. Frequently the gray 
nodules follow the distribution of the blood-vessels. (2) In many 
cases there is little or no inflammatory exudate, although petechial 
hemorrhages are common. (3) The peritoneum, howeyer, has not 
its normal shining surface, but is usually pale, somewhat sticky, and 
lustreless. (4) In many cases there is an effusion of straw-colored 
or bloody fluid which may amount to a litre or more. It contains a 
considerable amount of albumin and some cells. The exudate is rarely 
purulent. II. Chronic Diffuse Form. — (1) The abdominal viscera 
and peritoneum are bound together by tough, firm, membranous bands 
of organized exudate and the peritoneal cavity is obliterated. (2) 
The intestinal coils are shortened and contracted, while the mesenteries 
and omentum are enormously thickened. (3) The capsules of the 
liver and spleen undergo extreme thickening, varying from a few 
millimetres to several centimetres. The organs are rough and irreg- 
ular in outline. III. Ulcerative Form. — (1) There is a formation of 
caseous masses that vary in size from a pea to a marble, and which 
tend to run together and break down, forming more or less extensive 
ulcerating surfaces. (2) Adhesions are formed of a ' serofibrinous or 
seropurulent character. (3) The new tissues are apt to become pig- 
mented and of a gray or almost black color. (4) The intestinal walls 
are very friable. (5) Fistulse, opening at various points, are not 
infrequent. 

Tuberculosis of Serous Membranes. — There are three groups of 
cases: (1) Acute miliary tuberculosis, which may develop very rap- 
idly and is accompanied by more or less serous but turbid exudate. 
(2) A chronic form characterized by exudation, the formation of 
cheesy masses, and a tendency to suppuration. (3) Cases in which 



MICRO-ORGANISMAL DISEASES 237 

the tubercles are hard and fibroid, the membranes much thickened, but 
with little or no fluid exudate. In these cases there may be no visceral 
tubercles. 

Tuberculosis of the Skin. — Anatomical warts are small papillary 
outgrowths frequently seen on the hands of those who make many 
autopsies. The process is chronic, and, as in the case of one of my 
helpers in the post-mortem room at Blockley, may give rise to general 
tuberculosis. The bacilli are few, and are best demonstrated by inocu- 
lation of some of the secretion into a guinea-pig. The animal lives for 
a longer period of time than is usual when it is inoculated with tuber- 
culous material taken from other sources. Lupus vulgaris is a cuta- 
neous form of tuberculosis, characterized by the formation of nodules, 
which tend to break down, producing more or less ulceration. The 
tubercle bacillus is found in very few numbers. ( 1 ) The lesion begins 
as a small nodule, reddish brown in color and of soft consistence. 
These nodules vary in size from a pin-head to a cherry and quickly 
break down and ulcerate. The ulcers are more or less rounded and 
have a red base covered with granulations. The intervening tissues 
show diffuse infiltration and fibrous hyperplasia. Warty excrescences 
may develop in the epidermis or in the floor of the ulcers. The face 
is the most common seat of the disease. (2) In lupus of the larynx the 
lesion is surrounded by hypersemic, cedematous tissue. In the course 
of time smooth, hard nodules appear, causing great deformity of the 
parts. Softening and ulceration give the larynx a worm-eaten appear- 
ance. The disease follows the lymphatic channels. 

Typhoid Fever. — The intestinal lesions are: First week, intense 
catarrhal inflammation of the mucous membrane of the intestines 
and in the first few days only moderate swelling of the follicles. 
Towards the end of this week, however, there is more decided 
medullary swelling. Second week, the medullary swelling goes on to 
resolution or formation of eschar or, third week, ulcer formation. In 
the fourth week there is beginning cicatrization. The lesions are most 
marked in the lower ileum, but they also exist in the caecum and large 
intestines, rarely in the jejunum. Hyperplasia of the mesenteric lym- 
phatic glands and the spleen develops early in the disease. Cloudy 
swelling and fatty degeneration of the heart, liver, and kidneys may 
be present. Waxy degeneration and bleeding in the voluntary muscles 
should be looked for. Other lesions are lymphoma of the liver, acute 
nephritis, bleeding of the skin, hypostatic or catarrhal pneumonia, 



238 POST-MORTEM EXAMINATIONS 

purulent bronchitis, perforation, and peritonitis. The Widal test and 
the diazzo-reaction may be determined post mortem. Paratyphoid or 
paracolon infections are more common than was formerly supposed, 
and furnish most interesting cases for thorough study. 

Yellow Fever. — The chief lesions are: (1) Bleeding from the 
mucous membranes. (2) Tarry blood. (3) High-grade fatty degen- 
eration of the liver. (4) Acute hemorrhagic inflammation of the 
stomach and intestinal mucous membrane. (5) Icterus. The inter- 
esting work done by Reed, Carroll, and Agramonte in Havana, in 
showing that this disease is dependent on the Stegomyia, a variety of 
mosquito, is one of the most important contributions to medical litera- 
ture of the past decade. The bacillus X of Sternberg and the bacillus 
icteroides of Sanarelli are by some supposed to be identical, by others 
not to be the cause of yellow fever. There is an interesting illustrated 
article on this subject in the New Orleans Medical and Surgical Jour- 
nal for January, 1902. 

PARASITES. 

Pediculi. — (a) Pediculus capitis. — The female louse measures 
from one and eight-tenths millimetres to two millimetres in length, 
the male being somewhat smaller. The darker the skin of the person 
infested the darker is the color of the parasites. So marked is this 
peculiarity that some writers are of the opinion that different species 
affect different races. The ova are grayish glistening specks enclosed 
in a membrane firmly adherent to the shaft of a hair not far from its 
root, and coming off at an acute angle, with the opening away from 
the scalp after the exit of this parasite. Considerable irritation is 
caused by these animals, and when this is severe the hair on the back 
of the head may be found matted with soft yellow crusts. The scalp 
is covered with moist red granulations. The cervical lymphatic glands 
posteriorly are enlarged. This condition is most frequently seen in 
children, (b) Pediculus pubis. — It differs slightly from the above in 
that it is smaller and infests regions, as the axillary, the pubic, and 
the periocular, where the hair is short, (c) Pediculus corporis is the 
largest form of the parasite. It lives in the clothing, when not in search 
of food on the body. By its constant irritation it causes dermatitis, 
and if present for a long time, pigmentation and thickening of the skin. 
(d) Cimex lecHdarius (common bedbug), (e) Pulex irritans (the 
common flea), (f) Pulex penetrans (sand-flea, jigger). The latter 



PARASITIC DISEASES 



239 



is common in tropical and subtropical countries. It is smaller than 
the common flea. It burrows under the skin and produces a pustular 
swelling, (g) Sarcoptes (Acarus) scabiei. — The female itch-mite is .45 
of a millimetre long and .35 of a millimetre broad; the male is about 
one-half the size. Its color is pearly white. The burrow in the skin, 
wherein may be found the excrement and the eggs of the parasites, 
is about one centimetre in length, and is present where the skin is 
moist, as in the webs of the fingers and toes. Cutaneous lesions result 
from the scratching instigated by the irritation caused by the parasite. 
Cestodes. — Instestinal Cestodes. — (a) Tcenia solium in the ma- 
ture form may reach to twelve feet or even more in length. It is 
composed of numerous segments about one-third of an inch long and 
averaging a fourth of an inch wide. The head is very minute, being 
no larger than the head of a pin. In front is a rostellum and at the 
base of this is a fringe of hooklets. It has four suckers. The worm 
is hermaphroditic. When mature thousands of ova are passed by the 
rectum. The embryo has six hooklets. It penetrates the walls of the 
stomach and burrows into the tissues of the animal that has swallowed 
it. ( b ) Tcenia saginata is larger, longer, and of more frequent occur- 
rence than the preceding. The head is nearly square and measures 
more than two millimetres in breadth, but has no hooklets. The seg- 
ments are larger than those of the Tcenia solium. The reproductive 
organs are on the ventral aspects of the segments in the median lines. 

(c) The Bothriocephalic lotus is larger and longer than any of the 
flat worms. In the mature state it is twenty-five feet or more in length. 
It has no hooklets, but is furnished with slit-like fossae on the head, 
which act like suckers. The larvae develop in the peritoneum of fish. 

(d) Tcenia ilavopunctata is very rare. It is about sixteen centimetres 
long, (e) The Cysticercus cellulosce is the larval form of the Tcenia 
solium. It is found in the muscles, brain, cord, peritoneum, or almost 
any other tissue of the affected animal. The surrounding capsule is 
frequently calcified. In the making of many autopsies it is surprising 
how few taenia are found in the intestinal tract. My experience is lim- 
ited to but two cases. One of these was that of a man who committed 
suicide with opium. Two Tcenice saginatce were found, the head of the 
first one being firmly attached beneath a fold of one of the valvulae 
conniventes high up in the jejunum and the other five or six feet far- 
ther down the intestine, the segments of both worms then continuing 
on down to near the ileocaecal valve. 



240 



POST-MORTEM EXAMINATIONS 



Nematodes. — (a) Ascaris Lumbricoides. — It is a cylindrical 
worm with both ends pointed. The female is from ten to sixteen 
inches in length, the male considerably smaller. It is brownish yellow, 
reddish, or white in color. The head ends in three lips, (b) The 
Oxyurus vermicularis (seat-worm) is a very small round worm, about 
ten millimetres long, (c) The Trichina spiralis in the mature state 
lives in the intestine; in the immature state in the muscles. The em- 
bryo is surrounded by a capsule, which quickly calcifies. Under the 
microscope the embryo can be seen coiled up in its capsule; it is less 
than a millimetre in length. (d) The Anchylostomum diiodenale 
lives in the upper part of the intestine. The female is the larger, and 
varies from ten to sixteen millimetres in length. At the anterior por- 
tion of its head are hooklets, with which it attaches itself to the intes- 
tinal walls. It is frequently associated with Egyptian chlorosis. Stiles 
and Harris have recently called attention to the wide distribution of 
uncinariasis in the South; the disease may be readily recognized by 
finding the ova in the faeces, (e) The embryo of the Filaria sanguinis 
hominis is a round worm one-seventy-fifth to one-one-hundredth of an 
inch long. It is enclosed in a delicate sac. It circulates freely in the 
blood, but only at night. The adult parasite is located in the lym- 
phatic vessels and is three or four inches in length. According to 
Manson, it is introduced into the body by the mosquito. 

Distomiasis. — (a)' Liver-flukes. (b) Blood-flukes. These 
worms are lanceolate in shape, quite flat, and possess a distinct head 
and neck. They are three- fourths of an inch long and about half an 
inch broad. The color is dull brown. The female blood-fluke has a 
grooved channel posteriorly for the reception of the male. They have 
two suckers, one near the mouth and the other near the ventral portion 
of the body. The liver-fluke infests the upper intestine and the bile- 
ducts. It causes the " liver-rot" in sheep. The blood-fluke is found 
chiefly in the portal system and the veins of the bladder. The ova 
may be seen in the urine as elongated ovoid bodies, sharply pointed at 
one extremity, and containing black pigment. They can easily be 
seen with a low power of the microscope. Parasitic haemoptysis now 
occurs in America as well as in Asia, and is due to the Paragonimus 
Westermanii. The eggs are found in the sputum, the fluke measuring 
from eight to sixteen millimetres long by four to eight millimetres 
across. 

Myiasis. — By this term is meant a condition in which a diseased 



H/EMATOZOIC DISEASES 241 

part becomes " living," as it is called. It is caused by the larvae of 
certain flesh-flies, of common house-flies, or of the bot-flies of oxen or 
sheep. The ova of these flies may be deposited in the nostrils, ears, 
conjunctiva, open wounds, or even in the vagina during the puer- 
perium. 

Echinococcus Disease. — A parasitic disease, found most fre- 
quently in those countries, as Iceland and Australia, where the dog 
lives in intimate association with man; it is characterized by the 
formation of endogenous or exogenous multilocular cysts in various 
portions of the body. The Tamia echinococcus is a very small, thread- 
like tape- worm (length from three to six millimetres), having only 
three segments. The head has four suckers, a rostellum, and a double 
row of hooklets. The adult worm is found in the dog. The embryos 
(scolices) are found in the ox, hog, sheep, horse, and man. Distribu- 
tion in Man. — (a) Liver (most common), (b) Lung and pleura. 
(c) Intestinal tract, (d) Kidney, brain, etc. The embryo, freed from 
the cyst by digestion in the stomach, burrows through the intestinal 
wall and is carried to the various organs; it then loses its hooklets 
and is gradually converted into a cyst (hyatid) having two walls, ex- 
ternal laminated, internal granular or parenchymatous, containing 
blood-vessels and muscle-fibres. The interior is filled with a clear non- 
albuminous fluid, specific gravity 1005- 1009, usually containing sugar 
and hooklets. From irritation of surrounding tissues a fibrous capsule 
generally develops on the outside. The cysts vary in size from that of 
a small pea to that of a child's head. From the inner (parenchyma- 
tous) layer may develop brood capsules, which in their turn produce 
numerous scolices. The cysts grow slowly; when the embryo dies, 
the whole becomes calcified. Sometimes the cysts suppurate; occa- 
sionally they rupture into adjacent structures. 

H^EMATOZOA. 

Malaria. — This widely distributed and much-studied disease is 
due to a true haematozoon, transmitted to man by the bite of the ano- 
pheles mosquitoes. Three varieties have been described: (a) Tertian. 
(b) Quartan, (c) iE'stivo-autumnal. Classification. — (a) Acute ma- 
larial fever, which may be quotidian, tertian, or quartan, (b) Per- 
nicious malaria, (c) Chronic malarial cachexia. In the blood of the 
cadaver the plasmodium is seldom visible, but it may be found in sec- 
tions of the brain, liver, and spleen. ( 1 ) Cases of simple malarial fever 

16 



242 



POST-MORTEM EXAMINATIONS 



are rarely fatal. The blood shows disintegration of red corpuscles and 
an accumulation of pigment is thereby formed. The spleen is enlarged, 
dark in color, and may show pigmentary deposits. (2) In pernicious 
malaria the blood contains enormous numbers of the parasites. The 
red corpuscles are in all stages of destruction and the serum is tinged 
with haemoglobin. The spleen is moderately enlarged. The pulp is 
soft, chocolate-colored, and turbid; it contains large numbers of red 
corpuscles and parasites and the amount of pigment is greatly in- 
creased. The liver is swollen and presents areas of focal necrosis and 
capillary thrombosis. Pigmentary deposits are also common. The 
kidneys present more or less parenchymatous change with only mod- 
erate pigmentation. (3) In malarial cachexia the blood presents all 
the characteristics of an advanced anaemia, often distinguishable from 
pernicious anaemia only by the presence of the parasite and icterus. 
The spleen is greatly enlarged : it may weigh from seven to ten pounds. 
The organ is firm and resistant to the knife. The capsule is thickened 
and the parenchyma brownish or slate-colored, with areas of pigmen- 
tation. The kidneys are enlarged and of a grayish-red color. The 
peritoneum is thickened, opaque, and of a deep slate-color ; the gastric 
and intestinal mucous membrane may have the same hue. The gray 
matter of the brain is of a deep reddish-gray color or in very chronic 
cases a chocolate-brown. The meninges are congested. (4) Among 
accidental and late lesions is cirrhosis of the liver. Very extensive 
pigmentation may occur. Pneumonia is believed to be common ; mod- 
erate albuminuria is frequent; acute nephritis is not uncommon; 
chronic nephritis may follow long-continued or repeated infection. 
Rupture of the capsule of the spleen may occur, followed by bleeding 
into the peritoneum and even peritonitis. In pernicious malaria the 
brain may show thrombosis, due to the parasites, with secondary soften- 
ing of the surrounding tissue. The same thing may be found in the 
gastro-intestinal mucosa and be followed by superficial ulceration. 
There may be advanced fatty degeneration of the heart. 

Psorospermosis. — A condition produced by the presence of oval, 
transparent bodies belonging to the coccidia, to which class the mala- 
rial organism also belongs. I. (1) In the majority of cases of the 
internal form the psorosperms have been found in the liver. (2) 
Whitish growths resembling tubercles and containing the coccidia 
have been found upon the peritoneum, omentum, and pericardium. 
(3) Similar masses are sometimes seen in the ileum, liver, spleen, and 



H^EMATOZOIC DISEASES 243 

kidneys. The liver may be enlarged and contain caseous foci which 
are surrounded by areas of congestion. (4) The spleen may be simi- 
larly affected. II. ( 1 ) In cutaneous .affections the lesions closely 
resemble those of tuberculosis of the skin. They occur in Paget's 
disease of the nipple and by some are believed to be its cause. ( 2 ) A 
case has been reported in which at autopsy nodules were found in the 
lungs, adrenals, testicle, spleen, on the surface of the liver, and on 
the pleurse. Great numbers of psorozoa were found in the lesions. 
(3) Successful inoculations were made into rabbits and dogs. 

Trypanosoma. — Four animal diseases are caused by varieties of 
trypanosomes, nagana, surra, mal de caderas, and dourine. Recently 
Nepveu, Dutton, and others have found them in man. 



CHAPTER XXIII 

THE PRESERVATION OF TISSUES FOR MICROSCOPIC AND MACROSCOPIC 

PURPOSES 1 

When tissues are to be preserved for microscopical study, the 
method of fixing and hardening them should be decided upon at the 
time of their removal from the body. The objects of fixation and 
hardening are permanently to solidify the structural elements of a 
part as nearly as possible in their original form and situation. All our 
present methods, however, fail to give an accurate picture of the living 
cell, and not enough attention is now paid to the microscopical exami- 
nation of unstained fresh scrapings removed during the performance 
of the autopsy. The best slides are secured by the use of different 
processes for various purposes. The use of perfectly fresh tissues is 
essential, for many structural details disappear on molecular death. 
Fortunately, this does not occur until several hours after molar death, so 
that it is often possible to obtain tissues still living. 2 Our choice of 
reagents also is constantly being enlarged. The method of wrapping 
tissues in paper or cloth and transporting them to a distance is only 
to be regarded as a last resort. When this is done, pieces of sufficient 
size to insure preservation of their interior intact are enveloped in an 
abundant supply of clean cotton (antiseptic gauze causes markings 
on them), moistened very slightly with a bichloride-tablet solution, 
and thoroughly protected from pressure ; these segments are cut down 
to a proper size before they are put into the fixing agent in the labo- 
ratory. The careless wrapping of tissues in cloth or paper is mentioned 
only to be condemned. 

Bottles containing the more common fixatives should be ready, 
and as soon as the tissues are exposed and described — before the part 

1 Based on the works of Lee, The Microtomist's Vade Mecum; Mallory and 
Wright, Pathological Technique ; Apathy, Die Mikrotechnik der thierischen Mor- 
phologic; Fischer, Fixirung, Fdrbung, und Bau des Protoplasmas ; Szymono- 
wicz, Lehrbuch der Histologic ; Stohr, Text-book of Histology ; Bohm and Von 
Davidoff, Text-book of Histology, and the Encyklopddie der mikroskopischen 
Technik, 1903. 

2 A most inviting field of investigation is opened up by the experimental stain- 
ing of tissues during life and their fixation while the animal is still living. 

244 



PRESERVATION OF TISSUES 245 

becomes distorted, fluids escape, or surfaces dry — they should be cut 
with a clean, sharp knife into pieces about two centimetres in length 
and breadth and one centimetre thick. Sections of organs should in- 
clude their characteristic structures, — cortex, capsule, hilum, endocar- 
dium, etc. Sections of tumors should be taken from the centre, where 
degenerative changes are most marked, and from the growing periph- 
eral margin, if possible including some normal tissue; this is of espe- 
cial importance in the case of malignant tumors. Mucous and serous 
membranes are pinned out on cork, or wood that will give no stain 
when soaked in the preservative fluid to be used, with their secreting 
surfaces uppermost. Muscle-fibres are best preserved by being tightly 
stretched upon and tied at the ends of a piece of wood. The segments 
of tissue, without being touched by either fingers or forceps, ai e lifted 
on the blade of the scalpel and dropped immediately into a bottle con- 
taining an amount of fixing fluid far in excess of their bulk. Of 
energetic fixatives, such as Flemming's or Hermann's, about fifteen 
times the volume of the object introduced will suffice, while of milder 
fluids, like the bichromate of potassium or picric acid solutions, one 
hundred times such volume will be required. 

If the different tissues are distinguishable macroscopically, they 
may be placed in the same jar ; if not, separate bottles are better. Tags 
may be attached, the writing being done with a lead-pencil, as they are 
not acted upon by the usual preservatives. The jars are labelled with 
the date, the number or name of the autopsy, and the fixative used. 
It is often of importance to add the exact locality from which the 
pieces have been removed and the plane on which they are to be cut 
when placed in the microtome. 

The fluid should always be changed after it becomes turbid; or 
in the case of alcohol or formalin, preferably after three hours, whether 
it is turbid or not. If the specimens are to be sent away, they should 
not go until the fluid remains clear; if the time necessary for trans- 
portation exceeds that of the proper action of the fixative, they should 
be worked on up to 80 per cent, alcohol and shipped in that fluid, firmly 
packed in absorbent cotton. 

The choice of a fixing agent is determined by the nature of the 
object to be preserved and the purpose for which the investigation is 
undertaken. The characteristics of different pathological conditions 
are better preserved in some fixatives than in others. Thus, fatty 
degenerations are well preserved by an osmic acid, bichromate, or 



246 



POST-MORTEM EXAMINATIONS 



formalin solution; oedematous and parenchymatous changes, by cor- 
rosive sublimate ; fibrin and hemorrhagic conditions, by absolute alco- 
hol, etc. Moreover, different tissues require different treatment; the 
fixation of a lymph-node is quite a different matter from that of a 
retina. Then the purpose for which the examination is made will 
largely influence the choice. If it be simply a question of general 
diagnosis, Orth's fluid and alcohol will answer every purpose; by 
the use of alcohol we can preserve the specific staining properties of 
micro-organisms and haemoglobin and various important chemical re- 
actions, and by the use of Orth's fluid colloid and mucoid material 
retain their transparency, fat is preserved, etc. If we undertake the 
investigation of pathological processes and the comparison of abnormal 
with normal cellular anatomy, then special fixatives must be used. 

The advantages and disadvantages of the fixing solutions most in 
use will first be given, next a list of pathological conditions and the 
solutions best calculated to preserve their characteristics, and finally 
a list of staining solutions requiring certain fixatives for their use. 

Fixatives ; Insolubility. — To preserve soluble cell contents they 
must first be rendered insoluble, and the transformation must be equable 
throughout. The colloid or fluid material must harden homogeneously 
and enclose the more solid structures without loss of former relation- 
ship : there must be no shrinkage, no condensation, no expansion ; but 
everything should be precisely as it was when manifesting vital activi- 
ties, except this change into a compound that will remain undissolved 
and persist through subsequent necessary manipulations. This insolu- 
bility is supposed to be due in some cases to a sort of clotting process ; 
and if the coagulating property be stronger in absolute alcohol than its 
dehydrating power and less in alcohol of lower percentage, this fact ex- 
plains why more shrinkage is caused by 96 per cent, than by absolute 
alcohol, and why the shrinkage increases with the lowering of the 
alcoholic strength. Other fixing agents, such as osmic acid, chromic 
acid, potassium bichromate, and corrosive sublimate solutions, seem 
to form a chemical union with the cell contents and so produce an 
extremely durable insolubility. Others, such as picric acid and nitric 
acid, harden well, but form such unstable compounds that the fixation 
is easily removed by washing in water and must be preserved by 
placing the specimens in alcohol. It is evident that any solvent action 
by the reagent — e.g., the action of alcohol on fat and that of acetic 
acid on protoplasm — forbids its use. 



PRESERVATION OF TISSUES 247 

Optical Differentiation. — Some agents in producing insolu- 
bility effect another change which is equally valuable and which is 
known as optical differentiation. The various cell structures respond 
differently to the fixative. Their indices of refraction are altered; 
some are raised, some lowered, and marked contrasts in refractive 
properties are developed throughout the cell. In this way structures 
become visible that were before unseen. Bichromate of potassium 
stiffens very equably, with neither shrinkage nor expansion, but has 
no power of optical differentiation; while osmic acid possesses this 
in a high degree. Since observation with the microscope is directly 
dependent upon differences in refraction, it is evident that this is a 
most valuable property of a fixative. 

Penetration. — The ability to reach all points of the tissue at the 
same time is another important characteristic of a fixing agent and 
one clearly connected with securing optical differentiation. Osmic 
acid has but little penetration. If pieces placed in its solutions are 
too thick or remain therein too long, the superficial layers become 
over-exposed, the indices of refraction are all equally raised, and 
differentiation disappears. This is true not only of- cells in mass, but 
also of intracellular structures. Prompt and uniform action, the sharp 
fixation of tissues at the precise moment, insures good optical differ- 
entiation ; slow, unequal action results in loss of definition. 

Fixing Fluids. — All acids apparently possess fixing properties, 
and every fixing fluid should be acid, with possibly the exception of 
alcohol. Of the organic acids acetic and formic are those most used; 
of the inorganic, nitric, sulphuric, picric, hydrochloric, osmic, and 
chromic. 

Acetic Acid. — By this term is always meant glacial acetic acid, 
which has very great penetrating power and aids in optical differen- 
tiation. It causes swelling and solution of protoplasm, and hence is 
not used alone, but with fixatives such as osmic acid to aid in penetra- 
tion and prevent excessive blackening, with alcohol and corrosive sub- 
limate to prevent shrinkage, and with chrome salts to aid in optical 
differentiation. It is usually added to these various solutions in 
strengths varying from 0.5 to 5 per cent. All liquids containing a 
large percentage of acetic acid should be allowed to act only for a 
short time. Acetic acid should not be used for connective tissue. 

Alcohol (95 per cent, or absolute; 2-24 hours; 5 mm. thick). — 
Alcohol has certain important advantages. It can be readily procured, 



248 POST-MORTEM EXAMINATIONS 

does not have to be made up, tissues are hardened as well as fixed 
by it, and, since it represents one of the last stages preparatory to 
embedding, its use saves much time and trouble, and the material for 
a general diagnosis is easily and promptly prepared, which is often 
a great convenience. It penetrates well, preserves the specific staining 
properties of micro-organisms and various important chemical reac- 
tions, permits the use of most stains and is demanded by others, — 
e.g., Nissl's, Lenhossek's, Weigert's, Ribbert's phosphomolybdic haema- 
toxylin, Unna's orcein, etc. It is especially good for glands, skin, 
and blood-vessels, mast-cells, plasma cells, fibrin, and hyperaemic con- 
ditions, since it preserves the color-reactions of haemoglobin. On the 
other hand, it sometimes causes shrinkage and exerts a bad solvent 
action, so that the cells come out lean and empty, with foamy, vacuo- 
lated protoplasm and with distortion or loss of original structure. 

Tissues should not remain too long in absolute alcohol, as they 
sometimes stain very poorly after as short a time as twenty-four hours. 
Alcohol is not a good fixative for van Gieson's stain. Alcohol of 
lower percentage than 95 causes excessive shrinkage. 

The shrinkage of alcohol is corrected by the use of acetic acid. 

Carnoy's fluids (for nuclear structures) : 

1. Glacial acetic acid 1 part. 

Absolute alcohol 3 parts. 

2. Glacial acetic acid 1 part. 

Absolute alcohol 6 parts. 

Chloroform 3 parts. 

Leave pieces in for from fifteen to thirty minutes; wash out in alcohol. 
Avoid aqueous liquids. 

(For acetic alcohol with sublimate see " Gilson's solution" and 
" Ohlmacher's solution" under Corrosive Sublimate.) 

After the use of alcohol as a fixing agent, tissues must either be 
embedded in celloidin or paraffin as soon as hardened or left in cedar 
oil, or put through 95 per cent, alcohol and finally preserved in 80 per 
cent. 

Chromic Acid. — Chromic acid is a powerful and rapid coagulating 
agent, but, on account of its lack of penetration and tendency to cause 
shrinkage and make tissues brittle, it is seldom used alone. Its de- 
fects are remedied by adding acetic, formic, osmic, or nitric acid to 
its solutions. All tissues fixed by chromic acid solutions are to be 
washed in running water and hardened in graded alcohols in the dark. 



PRESERVATION OF TISSUES 249 

Chromo-acetic acid (Rabl) : 

Acetic acid, 0.1 per cent, in water 1 part. 

Chromic acid, from 0.2 to 0.25 per cent 1 part. 

Chromo-formic acid ( Rabl ) : 

Chromic acid, 0.33 per cent 200 cc. 

Formic acid, concentrated from 4 to 5 drops. 

Use at once, fix for from twelve to twenty-four hours. 

Chromo-nitric acid (Perenyi) (4-5 hours) : 

Nitric acid, 10 per cent 4 parts. 

Alcohol 3 parts. 

Chromic acid, 0.5 per cent 3 parts. 

Transfer directly to 70 per cent, alcohol for twenty-four hours, to 95 
per cent, for some days, and to absolute alcohol from four to five days. 

Chromo-osmic acid has been superseded by 

Chromo-aceto-osmic acid (Flemming) : 

Chromic acid, 1 per cent 45 cc. 

Osmic acid, 2 per cent 12 cc. 

Glacial acetic acid 3 cc. 

Objects may stay in this solution for hours or even several days. The 
pieces should be perfectly fresh and not thicker than 4 mm. 

It should be made up shortly before using. When all the condi- 
tions are fulfilled, it is unequalled as a fixative and in producing optical 
differentiation. The most delicate structural details are brilliantly 
shown. Especially used for mitotic figures. 

Bichromate of Potassium. — The simple aqueous solution is used 
in gradually increasing strengths from 2 to 5 per cent, for harden- 
ing purposes, for which it is excellent, but, on account of its lack of 
penetration and tendency to cause the chromatin to swell, it is not 
suitable for a nuclear fixing agent without being reinforced. The 
addition of glacial acetic acid gives a fluid which acts nearly as well 
as Zenker's and is much more convenient to use. The excess of bi- 
chromate is to be well washed out in running water and the tissues 
hardened in alcohols in the dark. 

Acetic bichromate (Tellyesniczky) (1-2 days) : 

Bichromate of potassium 3 grammes. 

Glacial acetic acid 5 cc. 

Water 100 cc. 

Begin hardening with 1 5 per cent, alcohol. 



250 



POST-MORTEM EXAMINATIONS 



Osmic, bichromate, and platinum chlorid (2 hours) (Dr. Lindsay 
Johnson) : 

Potassium bichromate, 2.5 per cent 70 parts. 

Osmic acid, 2 per cent 10 parts. 

Platinic chlorid, 1 per cent 15 parts. 

. Acetic or formic acid (just before using) 5 parts. 

A fine fixative for delicate objects, such as a retina. Leave objects in 
for two hours. Wash in running water. Harden in alcohol. 

The slow, mixed, and rapid methods of Golgi stain the cells with 
their prolongations, the nerve-fibres with their terminal ramifications, 
and the neuroglia cells. 

Golgi's slow method : Harden pieces of tissue in a 2 per cent, 
solution of bichromate of potassium from two to six weeks. Keep in 
the dark and change often. Transfer to a 0.75 per cent, aqueous solu- 
tion of silver nitrate. 

Golgi's mixed method : Harden small pieces of tissue for from 
three to five days, or longer, in a 2 per cent, solution of potassium 
bichromate at 25 ° C. in the dark. Place in the following solution for 
from three to eight days. 

Osmic acid, 1 per cent 2 parts. 

Bichromate of potassium 8 parts. 

Then into a 0.75 per cent, silver nitrate solution. 

Golgi's quick method : Tissues should be absolutely fresh, and the 
pieces not more than three millimetres thick. 

Osmic acid, 1 per cent 1 part. 

Bichromate of potassium, 3.5 per cent *. 4 parts. 

Leave pieces of neuroglia in the solution for two or three days, nerve- 
cells from three to five days, nerve-fibres and collaterals from five to 
seven days. Then place in 0.75 per cent, silver nitrate solution. 
Miiller's fluid (6-8 weeks) : 

Bichromate of potassium 2.5 grammes. 

Sulphate of sodium 1. gramme. 

Water 100. cc. 

This fluid, once so universally used, is now largely replaced by 
better fixatives. It has all the faults of the plain bichromate solution 
and the same need of being reinforced. (For acetic acid and sub- 



PRESERVATION OF TISSUES 25 1 

limate additions see " Zenker's fluid" under Corrosive Sublimate; for 
formalin see " Orth's fluid" under Formalin.) It hardens evenly 
without shrinkage and gives very good consistency to tissues, but it 
is in no way a nuclear fixative. As a hardening agent for nervous 
tissue it has been almost entirely replaced by formalin. 

Pieces of tissue not larger than two centimetres are hardened in 
from six to eight weeks. Change daily for seven days, then once a 
week. Wash in running water twenty-four hours. Nervous tissue 
is placed directly in alcohol. 

Erlicki's Solution. — 

Potassium bichromate 2.5 grammes. 

Copper sulphate 0.5 to 1. gramme. 

Water 100. cc. 

This is an extremely good agent for hardening voluminous ob- 
jects. Its action is much more rapid than that of Muller's fluid. For 
microscopical work, however, it gives precipitates likely to be mis- 
leading and difficult to remove. It is used as a fixative for Freud's 
gold stain for nerve-fibres. 

Chlorid of Iron (Mallory) (3-5 days). — For peripheral nerve- 
fibres. 

Chlorid of iron 1 part. 

Distilled water 4 parts. 

Wash out thoroughly in water. Transfer to a saturated solution of 
dinitroresorcin in 75 per cent, alcohol for several weeks. Wash, 
dehydrate, etc. 

This stain may be used after Flemming or Muller. 

Corrosive Sublimate (Bichlorid of Mercury). — This is a very 
active penetrating and hardening agent, and since tissues are suffi- 
ciently affected by it in from three minutes to two hours and are then 
placed directly into alcohol, the process is a quick and convenient 
one. Carmin and van Gieson stains are particularly brilliant after 
it. The Heidenhain-Biondi triple stain requires its use. It is an 
especially good fixative for the alimentary tract; for cedematous tis- 
sues and albuminous degenerations, since it coagulates nearly as well 
as boiling water; it is used for connective-tissue fibrillar with Mal- 
lory's anilin-blue stain. Its disadvantages are that it causes shrink- 
age and the formation of precipitates which must be removed. If 
tissues are too long exposed to its action they become brittle, and if 



252 



POST-MORTEM EXAMINATIONS 



kept too long in alcohol they are very difficult to cut. Unless corrected 
by the addition of some other agent, poor optical differentiation is 
obtained, so that corrosive sublimate should be used only for general 
and not for cytological work. Pieces of tissue should not be larger than 
five millimetres, and must be removed as soon as they become thor- 
oughly opaque, otherwise they will be too brittle. All solutions con- 
taining this salt act much better when freshly made, as they deteriorate 
by standing. 

Sodium chlorid and bichlorid of mercury (Heidenhain's solution) : 
A saturated solution of bichlorid of mercury in 0.5 per cent, solution 
of sodium chlorid. 

Acetic sublimate : A saturated solution of corrosive sublimate in 
5 per cent, glacial acetic acid. 

Gilson's solution: 

Absolute alcohol 1 part. 

Glacial acetic acid 1 part. 

Chloroform 1 part. 

Sublimate to saturation. 

This liquid is one of the most penetrating and rapidly acting of any, 
if not the most. Wash out with alcohol containing tincture of iodin. 
Ohlmacher's solution (15-30 minutes) : 

Absolute alcohol 80 parts. 

Chloroform 15 parts. 

Glacial acetic acia 5 parts. 

Sublimate to saturation (about 20 per cent.). 

A cerebral hemisphere sectioned by Meynert's method is hardened in 
from eighteen to twenty- four hours. 
Zenker's fluid : 

Corrosive sublimate 5 grammes. 

Glacial acetic acid - 5 cc. 

Miiller's fluid 95 cc. 

Add the sublimate and acetic acid just before using. Leave tissues 
in from twenty-four to forty-eight hours. 

This fluid is comparable to that of Flemming in perfect fixation. 
It has better penetration, over-fixation is not so likely to occur, it gives 
better staining results, and is much cheaper. It is altogether most 
satisfactory. Eosin stains are especially brilliant after its use. Its 
one disadvantage is that the sublimate must be removed by placing 



PRESERVATION OF TISSUES 



253 



sections in 70 per cent, alcohol containing enough tincture of iodin 
to give it the color of a dark sherry wine ; but this is true of all sub- 
limate solutions. 

Bensley's solution (^2-2 hours) : 

Potassium bichromate, 1 to 2 per cent, solution in water. . 1 part. 
Corrosive sublimate, saturated solution in alcohol 1 part. 

Mix the two solutions just before use. Leave tissues in from one- 
half hour to two hours. Wash well in water. 

This solution is especially useful for the gastro-intestinal tract. 

Formalin. — This agent acts very rapidly; it causes no shrinkage. 
Cytoplasm and nuclei are well preserved. Mitotic figures are fixed. 
Haemoglobin and micro-organisms retain their specific staining re- 
actions. Fat is not dissolved; mucin is not precipitated, but remains 
transparent. Formalin is an especially valuable fixative for nervous 
tissues: an entire brain may be hardened in a 10 per cent, solution 
in from a week to ten days. It gives great toughness and elasticity 
to tissues, and is required for many methods of staining nerve-fibres. 
Pieces of nerve tissue ten millimetres thick may first be fixed in for- 
malin and then subjected to the action of any mordant desired. 

It is used in a standard solution of ten cubic centimetres of for- 
malin to ninety cubic centimetres of distilled water. Change after 
three hours. Tissues are fixed in from one to two days, but may re- 
main in the fluid indefinitely if the percentage of formalin is main- 
tained. 

Orth's fluid (1-2 days) : 

Potassium bichromate 2.5 parts. 

Sodium sulphate 1. part. 

Water 100. cc. 

Formalin 10. cc. 

Add the formalin just before using. 

This is Miiller's fluid with 10 per cent, formalin. It is one of the 
best general fixatives in use. 

Nitric Acid (3 per cent. ; 6 hours; 70 per cent, alcohol). — It gives 
toughness to tissues and is especially suitable for organs rich in con- 
nective tissue. Bichromate of potassium may be used after fixation 
in nitric acid. 

Osmic Acid. — This is one of the finest fixatives known, especially 
for cytoplasm. It has great power of rendering cell constituents in- 



254 POST-MORTEM EXAMINATIONS 

soluble and of developing optical differentiation, thus bringing to 
view structures previously unknown. As it has very little penetration, 
superficial cells may be overfixed and homogeneous. Carmin stains 
badly after its use, but hematoxylin is not affected. It is seldom 
used alone except for fixation by vapors. Very delicate objects are 
pinned out on the well-fitting cork of a wide-mouthed bottle and 
exposed to the vapors of a small quantity of a i per cent, solution 
poured into the bottle. A retina needs an exposure of some hours 
and is more equally fixed than when placed in the solution. Osmic 
acid solutions do not keep well and must be carefully protected from 
dust. Lee recommends a 2 per cent, solution in 1 per cent, chromic 
acid. This serves for vapor fixation and Flemming's solution. It may 
also be kept as a 1 per cent, solution in distilled water. (For Flem- 
ming's solution see " Chromo-aceto-osmic acid.") In making osmic 
acid solutions the capsule containing this acid is broken within the 
bottle containing the solution. Tellyesniczky 1 suggests as the best 
substitute for osmic acid the following : 

Potassium bichromate 3 grammes. 

Acidi aceti 5 cc. 

Aquas 100 grammes. 

Platinico-acetico-osmic-acid solution (Hermann's solution; 1-8 
days) : This celebrated reagent is Flemming's solution with platinic 
chlorid instead of chromic acid. 

Platinic chlorid, 1 per cent 15 parts. 

Glacial acetic acid 1 part. 

Osmic acid, 2 per cent 2 to 4 parts. 

Its action is comparable to that of Flemming's solution. The most 
delicate structures are faithfully preserved and well shown. 
Pianese's solution (36 hours) : 

Chlorid of platinum and sodium, 1 per cent, aqueous 

solution 15 cc. 

Chromic acid, 0.25 per cent, aqueous solution 5 cc. 

Osmic acid, 2 per cent, aqueous solution 5 cc. 

Formic acid, C. P 1 drop. 

For karyokinesis and the so-called cancer bodies. Pieces of tissue 
1 Arch. f. mikrosk. Anat., 1898, vol. Hi. p. 202. 



PRESERVATION OF TISSUES 



255 



must not be more than two millimetres thick. It gives very inter- 
esting results histologically. 

Picric Acid (2-24 hours). — Picric acid is an extremely pene- 
trating and delicate fixative. It hardens very slightly, and the insolu- 
bility caused by its action may be easily removed by washing in water ; 
hence its preparations should always be placed in alcohol. It is used 
as a saturated aqueous solution and in large quantity, — about one 
hundred times the bulk of the object. It is an excellent fixative for 
delicate serous membranes, which may be floated in it without retrac- 
tion or distortion. The omentum and peritoneum are well fixed in it. 

Picro-acetic acid : A saturated solution of picric acid in one per 
cent, acetic acid ; a very good fixative. 

Picro-sulphuric acid (Kleinenberg) : Add 1 cc. of concentrated 
sulphuric acid to 100 cc. of a saturated aqueous picric acid solution. 
Let stand for nearly four hours ; filter ; add double its volume of dis- 
tilled water. This is an excellent fixative for delicate embryos. 

Picro-nitric and picro-hydrochloric acid solutions are also used, 
but their action is essentially the same as that of picro-sulphuric. 

The advantages of picric acid solutions are that they give a very 
delicate fixative with excellent cutting qualities, and delicate mem- 
branes are not thickened excessively as with stronger reagents. 

Hardening. — To give to tissues a proper cutting consistency they 
are gradually hardened by being passed through a series of graded 
alcohols. For general diagnosis tissues may go from water into 70 
per cent, alcohol, then 95 per cent., and finally absolute alcohol, usually 
remaining twenty-four hours in each grade. Corrosive sublimate and 
Golgi tissues are to be placed for only a few hours in 95 per cent, and 
absolute alcohols, without passing through the lower grades. For 
finer work begin with 30 per cent, or even 15 per cent, alcohol, then 
use 50, 70, 80, 95, and absolute. When the tissues are passed from 
a lower to a higher grade of alcohol, surplus moisture should be re- 
moved with blotting-paper to avoid lowering the percentage of the 
next grade. 

Preservation. — After being fixed and hardened, tissues are usu- 
ally preserved in 80 per cent, alcohol. Those fixed by formalin may 
remain in a 10 per cent, solution thereof. Golgi preparations keep 
indefinitely in the silver nitrate solution. Corrosive sublimate tissues 
will not cut well if kept too long in any kind of alcohol; they had 
better be kept in cedar oil. 



256 POST-MORTEM EXAMINATIONS 

Pathological Conditions suggesting Certain Fixatives. — Acute in- 
fectious processes : Alcohol. 

Acute inflammatory exudates : The fibrin, leucocytes, and red 
blood-corpuscles of hemorrhagic conditions are preserved especially 
well in Zenker's fluid. 

Albuminous degenerations : Corrosive sublimate, Zenker, or boil- 
ing water. 

Amoebae coli : Stain especially well with Mallory's chlorid of iron 
haematoxylin ; any fixative may be used except perhaps formalin. 
Amoebae coli may be studied either in the faeces or in the tissues. Col- 
lect the faeces in a perfectly clean dry vessel, warmed in cold weather, 
and keep them at the temperature of the room. Add a drop of a weak 
solution of toluidin blue to a particle of the faeces, make a cover-slip 
preparation, and preserve in Farrant's medium. For the tissues fix in 
Heidenhain's or Bensley's solution, stain with iron haematoxylin or with 
a weak solution of toluidin blue. If a contrast stain is desired, stain first 
with eosin or benzo-purpurin, then for fifteen or twenty minutes with 
a weak solution of toluidin blue ; differentiate with alcohol. 

Amyloid degenerations : Corrosive sublimate, Zenker, alcohol. 

Blood : Make thin films on cover-glasses ; dry in air ; then place 
in absolute alcohol and ether, equal parts, for half an hour. 

Bone : For infectious processes, alcohol ; for histological purposes, 
Zenker, Orth. Bone must always be fixed before decalcifying. 

Bone marrow : Make smears on cover-slips. Fix pieces of bone 
marrow in Zenker or formalin. 

Cartilage: Alcohol, Zenker, Orth. 

Central nervous system : A whole brain may be hardened in about 
three thousand cubic centimetres of Muller's fluid. Change every day 
for a week, then every week for four weeks, and every two weeks 
thereafter; it takes about three months to complete the hardening. 
Keep in a refrigerator if the weather be very warm. Erlicki's fluid 
hardens better and its action is more rapid, hardening being accom- 
plished in about four weeks. 

In a 10 per cent, solution of formalin a whole brain may be hard- 
ened in from ten days to two weeks. Change the solution every day 
for three days, then every third day. Cerebral hemispheres may be 
sectioned by Meynert's method and hardened in twenty-four hours 
in Ohlmacher's solution. These methods are not recommended for 
fine work. Pieces not larger than one centimetre may be hardened 



PRESERVATION OF TISSUES 2 $J 

in formalin and then subjected to any bichromate or osmic acid mor- 
dant, including Golgi's methods. 

Ganglion cells : For Nissl's method fix in 96 per cent, alcohol. 
For Lenhossek fix in 90 per cent, alcohol (or 10 per cent, formalin) 
and follow with 96 per cent, alcohol. For Golgi methods use Golgi 
fixatives. 

Myelin sheaths : For Weigert fix with 5 per cent, bichromate until 
" ripe," — that is, until color contrasts between white and gray matter 
are well developed. For Marchi use Miiller's fluid. Use formalin for 
Busch-Mallory, Weigert, Weigert-Pal, and Heller. For Exner use 
1 per cent, osmic acid; change second day; leave pieces in for five 
or six days. 

Neuroglia fibres : These are not well preserved by chromates. For 
Weigert methods fix in formalin. For Mallory fix in ten per cent, 
formalin in a saturated aqueous solution of picric acid. 

Medulla, pons, and basal ganglia : They may be removed together 
en masse and hardened entire in formalin for from one to two weeks, 
then cut into parallel slices not over one centimetre thick, and mor- 
danted by Weigert's quick method or Mallory's or in any way de- 
sired. Golgi stains are not very applicable to the medulla. 

Axis-cylinders and their terminal processes : For Freud's or 
Stroebe's gold stain fix in Erlicki or Miiller. For Gerlach's method 
harden in 0.5 per cent, solution of bichromate of ammonium for from 
one to three weeks. (For Golgi see " Golgi methods" under Bi- 
chromate of Potassium. ) 

Degenerated nerve-fibres : Harden in Miiller or Erlicki for Marchi 
or Algeri methods, or harden in 10 per cent, formalin followed by 
Miiller and Erlicki. 

Peripheral nerve-fibres : Fix in chlorid of iron. 

Retina : The retina may be fixed in a 10 per cent, solution of for- 
malin; in Zenker's, Orth's, or Lindsay Johnson's solution, as given 
under Bichromate of Potassium; in equal parts of glacial acetic acid 
and osmic acid (2 per cent.) ; in equal parts of chromic acid and pla- 
tinic chlorid (each 1.4 per cent.) ; or it may be pinned out on a cork 
and exposed to the vapor of a 1 per cent, solution of osmic acid. 

Colloid material : Formalin or Orth. 

Connective tissue: For Ribbert's phosphomolybdic hematoxylin 
stain for fibrillar fix in alcohol. For Mallory's anilin-blue stain fix in 
corrosive sublimate or Zenker. 

17 



258 POST-MORTEM EXAMINATIONS 

Elastic fibres : For Unna's orcein method fix in alcohol. For Wei- 
gert fix in alcohol or formalin. 

Fatty changes : Flemming, Orth, Miiller, Erlicki, or formalin. 

Fibrin: For eosin hematoxylin, methylene blue, and Mallory's 
anilin-blue stain fix in Zenker or corrosive sublimate. For infectious 
processes and Weigert's method fix in absolute alcohol. 

Glands : Fix in absolute alcohol. 

Granulation tissue: Fix in Zenker, Flemming, or Pianese for at- 
tendant degenerations. 

Hyaline degenerations : Zenker, corrosive sublimate, Orth. 

Liver: For pernicious anaemia and amyloid degenerations fix in 
alcohol. For bile capillaries use Golgi method. 

Mast-cells : For Ehrlich's or Unna's methods fix in alcohol. 

Mucoid material : For Mallory's anilin-blue stain fix in Zenker or 
corrosive sublimate. For other stains use Orth or 10 per cent, for- 
malin. 

Myxomas: Zenker or corrosive sublimate. 

(Edematous conditions : Throw small pieces of tissue into boiling 
water for a minute or two, or fix in corrosive sublimate. 

Ovaries : For follicular degenerations use Flemming or Hermann 
if tissues are fresh, if not use Zenker, Orth, Carnoy, or Ohlmacher. 

Pancreas : For Altmann's granules fix in equal parts of a 5 per cent, 
solution of bichromate of potassium and a 2 per cent, solution of osmic 
acid. 

Plasma cells : Zenker is especially favorable for showing eosino- 
philes. 

Pus or purulent conditions : Orth, Zenker, or corrosive sublimate. 

Skin is best fixed in alcohol. 

Spleen : For Heidenhain Biondi triple stain fix in corrosive sub- 
limate. For eosinophiles or Ehrlich's triacid use Zenker or alcohol. 

Suprarenal : If fresh fix in Flemming or Hermann ; if not, in Ohl- 
macher, Zenker, or Orth. 

Thyroid : For colloid degeneration fix in Orth or 10 per cent, 
formalin. 

Fixatives. — The following list gives the fixatives used for the 
various stains. 

Alum hematoxylin : Stains very slowly after chromic solutions. 

Anilin blue (Mallory) : Succeeds best after Zenker or corrosive 
sublimate. It may be used after formalin. 



PRESERVATION OF TISSUES 259 

Biondi Heidenhain (see " Heidenhain Biondi"). 

Eosin and methylene blue : Best after Zenker. 

Freud's gold stain : For axis-cylinders and nerve terminals ; used 
after Miiller or Erlicki. 

Gold stains : Freud's, Stroebe's, after Miiller or Erlicki ; Gerlach 
after 0.5 per cent, bichromate of ammonium for from one to three 
weeks. 

Golgi chrome silver preparation : After Golgi fixing solutions. 

Heidenhain Biondi triple stain : Only after corrosive sublimate. 

Lenhossek : For ganglion cells 90 per cent, alcohol or 10 per cent, 
formalin, both followed by 96 per cent, alcohol. 

Nissl : For ganglion cells 96 per cent, alcohol. 

Orcein (see " Unna's orcein stain"). 

Phosphomolybdic acid hematoxylin : Best after alcohol. 

Phosphotungstic acid hsematoxylin : After 10 per cent, formalin. 

Thionin (Lenhossek's ganglion-cell stain) : 90 per cent, alcohol 
followed by 96 per cent, or formalin 10 per cent. 

Triple staining : Heidenhain Biondi only after corrosive subli- 
mate. 

Unna's alkaline methylene blue : Alcohol. 

Unna's orcein stain : For elastic fibres, alcohol. 

Weigert's stain : For fibrin and elastic fibres, absolute alcohol. 

Macroscopical Specimens. — If a microscopical examination of the 
organ to be preserved is desirable, portions of tissue therefor should 
be removed before anything is done towards preparing it as a gross 
specimen. 

If for any reason it be desirable to keep the specimen for a short 
time, it should be kept moist by being wrapped in cloths wet with a 
10 per cent, formalin solution. If the specimen is to be shipped, wrap 
it in a cloth wet with such solution and pack it in parchment-paper, 
rubber cloth, or sawdust. Parenchymatous organs of slaughtered 
animals will keep for a week packed in this way and, when sectioned, 
the tissues appear fresh. The organs of deceased animals do not keep 
as well. If the specimen is to serve for a bacteriological investigation 
and for inoculations, it should not be wrapped in any disinfecting 
agent, but simply packed in parchment-paper or rubber cloth. 

By a percentage solution of formalin is meant such a dilution of 
the commercial 40 per cent, (which is sold as formalin) as will reduce 
it to the desired strength. For instance, ten cubic centimetres of 



2 6o POST-MORTEM EXAMINATIONS 

commercial formalin added to ninety cubic centimetres of water pro- 
duce a 10 per cent, solution of formalin or a 4 per cent, solution 
of formaldehyde. The percentage of formalin must be maintained, 
as it is quickly exhausted; when there is no odor of formalin, the 
fluid should be renewed. 

It is not always necessary to save the entire organ to be examined, 
but enough should be preserved to show its relationship to the lesion. 

General Considerations. — Washing. — If alcohol be used as the 
preserving solution, blood and other impurities may be removed by 
a thorough washing with water. In other cases the parts should be 
carefully sponged with the preservative to be employed. 

Cavities should be distended with tow or absorbent cotton. The 
lungs should be placed in a jar and the jar filled by pouring the fluid 
through the trachea. Mucous and serous membranes should be pro- 
tected from the distortion caused by shrinkage by being pinned out 
on cork or on wood which will impart no color in soaking. A more 
elegant method is to sew the membranes over the edges of frames 
made of glass rods. The secreting surfaces of these membranes should 
always be uppermost. 

Compression of any part of the specimen should be avoided by 
the use of a soft cushion of absorbent cotton placed in the bottom 
of the jar. Jars made especially for museum preparations are prefer- 
able, but if necessary they may be replaced by such as are used by 
grocers and druggists for candy, etc. 

Preserving Fluids. — Alcohol is a convenient and efficient agent. 
It preserves form relationships very well, as in tumors, typhoid ulcers, 
invagination of the intestine, etc. ; but it destroys all contrasts in a 
pathological organ, such as a diseased lung or kidney, and makes 
recognition of the lesion very difficult. It bleaches the tissues and 
causes much shrinkage, so that natural appearances are not retained. 
The specimen is to be washed in water, then immersed in 60 per cent, 
alcohol (which is changed every day until it remains clear), and finally 
kept in 80 per cent, alcohol. To preserve the natural appearance of 
tissues, formalin followed by alcohol is used, and the specimen is 
finally placed in glycerin solution containing some salt of acetic acid, 
usually potassium. Formalin converts the haemoglobin into methsemo- 
globin and a brown color is developed ; alcohol changes the methaemo- 
globin into a red pigment, so that the flesh-color is restored. The 
tissues are so thoroughly hardened that they may be kept in the 



PRESERVATION OF TISSUES 2 6l 

glycerin solution without being thereby softened. The principles in- 
volved are simple, but their application requires experience and inge- 
nuity. All tissues do not respond equally to the treatment, and to 
retain some color peculiar to a certain pathological condition — such 
as prevails in icterus, for example — requires careful management. 
There are various formulae and different methods of applying them, 
but the two following are perhaps as simple and useful as any. It 
must always be remembered that if the tissues are placed in too strong 
formalin, or remain too long even in a weak solution, the alcohol will 
fail to transform the brown or gray pigment back into red. 

i. Place the fresh organ or a segment as large as the hand for 
from twenty-four to forty-eight hours in one of the following solu- 
tions. 

Kaiserling fluid : 

Formalin 200 cc. 

Water 1000 cc. 

Potassium nitrate 15 grammes. 

Potassium acetate 30 grammes. 

Melnikow-Raswedenkow : 

Formalin 10. parts. 

Sodium acetate 3. parts. 

Potassium chlorate 0.5 part. 

Distilled water 100. parts. 

It is well to wrap the specimen in wadding and pour the fluid over 
it. The wadding protects the organ from distortion due to com- 
pression. If the organs are very thick, incise them or inject the blood- 
vessels, ureters, etc., with the fluid. This should be done very gently, 
in order not to wash out the blood. 

Formalin is very injurious to the respiratory tract and the skin. 
Hence it is better when using it to wear rubber gloves and to keep the 
jars covered. 

2. After two days place the specimen in 60 per cent, alcohol, first 
removing the wadding. Two or three days later change to 80 per 
cent, alcohol, then to 90 or 93 per cent. 

3. The specimen is finally placed in the preserving fluid: 

Glycerin 400 grammes. 

Potassium acetate 200 grammes. 

Water 2000 grammes. 



2 6 2 POST-MORTEM EXAMINATIONS 

The solutions may be used several times, but a fresh preserving 
fluid is better, and it is even advisable to change it occasionally. 

Pick adds at once to the formalin solution 5 per cent, of Carlsbad 
salts, which prevents the formation of acid hsematin, while Marpmann 
uses fluorsodium both in the formalin solution and in the glycerin. The 
use of ten parts of an 0.8 per cent, salt solution with one part of the 
40 volume strength formalin is also recommended. 

Little John 1 recommends that fresh specimens or those preserved 
by any well-known method be kept in glass jars made air-tight by 
sealing their covers with gold size and putty. The one objection to 
this method is the vapor which collects in the jars. To avoid this the 
preparations are soaked for several weeks in glycerin and water and 
afterwards placed on wool to which some formalin glycerin is added. 
Perfectly washed stomachs from cases of poisoning, such as carbolic 
acid and the corrosive acids, require no preservative whatever, and 
when prepared in this manner retain their natural and characteristic 
coloring for many years. 

1 Journal of Pathology and Bacteriology, September, 1902. 



CHAPTER XXIV 

BACTERIOLOGICAL INVESTIGATIONS 

It frequently happens that the bacteriological investigation is a 
most important factor in the ultimate value of a post-mortem exami- 
nation, but, because of the lack of facilities or of knowledge of 
technic, it is neglected. In the first place, the cost of equipment, as in 
post-mortem sets, is very largely limited by the conveniences, rather 
than the necessities. Culture-tubes can be obtained from the larger 
pharmaceutical manufacturing companies and their agencies quickly 
and at reasonable rates. In the second place, the technic is not so 
complicated as to require especial skill, except in the finer manipula- 
tions and diagnoses. It is not unreasonable to expect the general prac- 
titioner who is not within easy reach of a pathological laboratory or of a 
board of health to be sufficiently equipped with apparatus and ade- 
quately trained to make cultures and even inoculations for diagnostic 
purposes. Of course, it is impossible under such circumstances to 
do the work of well-endowed laboratories and skilled bacteriologists, 
but the material can at least be studied until the time arrives for 
placing it in the hands of those devoting their especial attention to the 
study of bacteriology. 

As stated elsewhere, every operator should go to the autopsy pre- 
pared not only to save and to preserve morbid specimens, but also to 
provide for proper bacteriological investigation. 

The important factor in the technic of a bacteriological examina- 
tion is that all instruments shall be scrupulously clean and absolutely 
sterile, and all sources of contamination carefully guarded against 
in every possible manner. 

The fluid contents and accumulations in abscess and serous cavi- 
ties, especially meningeal, pericardial, peritoneal, and pleural, the 
blood, endocardial vegetations, ulcerated surfaces, and the cut surface 
of solid organs may present foci of bacterial invasion which are 
examined by " smear preparations" and cultures. 

Smear Preparations. — These are made in the following man- 
ner: Having a number of carefully cleaned and dried cover-slips in 

263 



264 POST-MORTEM EXAMINATIONS 

readiness, 1 with a platinum wire, which has just been sterilized by 
heating to a red glow in an alcohol flame or the upper (hottest) part 
of a Bunsen burner, a drop of the fluid is put in the centre of one 
slip and another slip is placed upon it; the two are very gently 
pressed together and then separated by sliding one over the other 
until they come apart, thus leaving the material thinly and quite 
evenly distributed over both slips. The same result may be accom- 
plished, though not so satisfactorily, by placing the drop near the edge 
of the slip and spreading it out by drawing a smooth-edged slide 
broad-side over it. Or the fluid may be spread with the platinum 
wire zigzag over the slide, instead of the cover-slip, because the 
former is easier of manipulation, not so readily broken by subsequent 
handling, and allows a larger field of observation. Should there not 
be sufficient fluid to make a satisfactory smear preparation, a little 
distilled water or physiological salt solution may be added to the 
glass before performing the above manipulations. 

The cover-slip or slide may be touched directly to a freshly cut 
surface of the solid organ, which has been incised with a scalpel 
sterilized by heat, or the material may be removed by a specially con- 
trived platinum spear having a hole in its end or in the ordinary 
manner with the ose. 

The " smear" being dried with very little or no heat, there yet 
remains to " fix" it on the glass. This is done by the routine method 
of passing the glass three times through a flame, with the smeared 
surface upward to avoid burning the material. In this way the 
albuminous organic matter is dried or coagulated and the bacteria 
are thus caused to adhere to the glass surface. In " fixing" very 
great care must be used to avoid the application of too high a tem- 
perature, — -shown by a brownish coloration, — which would seriously 
distort the bacteria, especially if the film had not been thoroughly 
dried previously. Such a preparation will keep for a considerable 
length of time, and can be safely and easily protected by gumming the 
clean surface to a piece of card-board cut to the size of the ordinary 
glass slide, on which also may be written all necessary data. The 
cards may then be packed in an ordinary pill box, care being exer- 

1 It is well to use new cover-slips which have been cleansed in strong nitric 
acid, washed in distilled water, and kept in alcohol to which a few drops of 
ammonia have been added. When wanted for use, they must be wiped dry between 
the fingers with a clean handkerchief. 



BACTERIOLOGICAL INVESTIGATIONS 265 

cised that the films do not come in contact with anything that will be 
liable to rub or scratch them. 

A diagnosis made from the study of smear preparations must 
often be corroborated by cultures, though such study will frequently 
offer valuable suggestions as to the kind of culture-media to employ. 
The negative value of a slide from a suspected syphilitic sore may be 
considerable and is not sufficiently appreciated. 

Inoculating Culture-Media. — For the formulae and methods 
of preparing culture-media and tubes the reader is referred to any 
standard work on bacteriology. 

Test-tubes containing any of the solid or liquid media may be 
inoculated at the place where the autopsy is performed when it is not 
so far from the laboratory as to endanger the growth of the culture 
by exposure to extremes of temperature. Sufficient heat is secured, 
however, by placing the tubes after inoculation, securely wrapped, in 
an inside coat-pocket. 

The culture-tube is held in the left hand, in an almost horizontal 
position, if the medium be liquid, between the thumb and index-finger. 
Should the tube contain a solid medium, such as blood-serum or agar, 
it is inverted. The ose, held in the right hand, is now sterilized by heat 
and cooled, while the cotton plug is removed from the test-tube by a 
cork-screw motion and held, inner part outward, between the index 
and middle fingers of the left hand in such a manner that it does not 
come in contact with any portion of the hand. With the tip of the 
platinum wire a small portion of the substance to be inoculated is now 
placed on the surface of the medium ; if this surface is slanting the 
fluid is rubbed gently over it, thus making a " smear" or " stroke" cul- 
ture, while the needle is thrust deep down into the medium if a " stab" 
culture is to be made. The ose is then withdrawn, the cotton plug 
reinserted, the needle sterilized, and the tube labelled and put in a 
warm place until it can be sent to the laboratory. 

If the culture is to be made from the surface of a solid organ, the 
method is the same, except that the organ is incised with a very sharp 
and absolutely sterile knife, and in addition it is well, as a precau- 
tionary measure, to sterilize the surface again before plunging the 
needle deep into the tissue. 

Post-mortem examination of animals dying from diseases pro- 
duced by experimental inoculation should always be made as soon as 
possible, so as to prevent the invasion of the tissue by other bacteria 



266 POST-MORTEM EXAMINATIONS 

than those causing the fatal malady; it may usually be done within 
twelve hours after death. Fig. 153 shows the position generally 
adopted for the performance of necropsies upon the smaller animals, 
such as the guinea-pig. It will there be seen that the body is placed 
on a board in the same position as in crucifixion and securely held 
there by nails driven through the feet and the tip of the nose. An 
external examination is first carefully made, the weight determined, 
temperature taken, etc., especial attention being paid to the wound 
of inoculation. 

Numerous smears and cultures are produced from cutaneous 
lesions and from the initial incisions, which are usually made with 
sterilized scissors, the parts having previously been moistened with 
alcohol or with a 1 to 500 solution of the bichloride of mercury. The 
skin is then dissected away and tacked to the board, so as not later 
on to contaminate the field of operation. After the strictest precau- 
tions — heat being* the agent employed for the sterilization of the 
instruments — the thorax and abdomen are opened. This is done by 
heating a knife to a red heat and bringing it in contact with the por- 
tion of the body or organ in which the culture is to be made. Nuttall's 
platinum spear may be used, instead of the platinum wire, for the 
purpose of removing the material. 

Every precaution should be taken to prevent dispersion of the 
bacteria, as, e.g., by the dropping of cover-glasses, which on becoming 
broken might cause infection later on. 

Portions to be preserved for microscopic study are put in fixing 
solutions, such as those mentioned in Chapter XXIII. 

When the postmortem is completed, the animal should be placed 
in a cloth wrung out with formalin and immediately cremated. The 
pan and all implements employed should be thoroughly sterilized by 
heat, and nothing should be left behind which in any way has come in 
contact with the blood or other portions of the body in which the 
pathogenic germs are to be found. 



CHAPTER XXV 

WEIGHTS AND MEASURES 

It is customary in this country and in England to give the weights 
of the organs in avoirdupois ounces, their dimensions in inches, and 
their capacity in cubic inches, though the metric system has more to 
commend it and is fast gaining favor in English-speaking countries. 
Troy weight is sometimes used and may give rise to much confusion. 

The grain is the same in both Troy and avoirdupois weights. The 
ounce avoirdupois is 437.5 grains, or 28.34 grammes. The ounce 
Troy is 480 grains, or 3 1 . 1 grammes. To convert grammes into avoir- 
dupois ounces divide by 28.34, into Troy ounces divide by 31.1. Con- 
versely, to convert ounces avoirdupois into grammes multiply by 
28.34 ; Troy ounces multiply by 3 1 . 1 . 

A kilogramme equals one thousand grammes, or 2.2 pounds. A 
gramme equals one thousand milligrammes, or 15.433 grains. A 
metre equals one thousand millimetres, or 39.37 inches. A litre equals 
one thousand cubic centimetres, or 61.027 cubic inches, and is equiva- 
lent to 2.1 13 American pints or 1.76 English pints. 

I. Average height (European standard) : 

Adult male 172 centimetres, or 5 feet 7.7 inches. 

Adult female 160 centimetres, or 5 feet 3 inches. 

New-born male 47.4 centimetres, or 18.66 inches. 

New-born female 46.75 centimetres, or 18.4 inches. 

When a child is two years old, it is about one-half as tall as it will be 
when fully grown. 

II. Average weight (European standard) : 

Adult male 65 kilogrammes, or 143 pounds (av. ). 

Adult female 55 kilogrammes, or 121 pounds. 

New-born child 3250 grammes, or 7.15 pounds. 

The American Insurance standard : 1 

A man of five feet and one inch should weigh 120 pounds. 

A man of five feet and three inches should weigh 130 pounds. 

A man of five feet and six inches should weigh 143 pounds. 

A man of five feet and nine inches should weigh 155 pounds. 

A man of five feet and eleven inches should weigh. . . . 165 pounds. 

1 From Finlayson's Clinical Manual. 

267 



268 POST-MORTEM EXAMINATIONS 

A child may be born weighing less than a pound and live. The 
greatest recorded weight attained by man is some iooo pounds. 

According to Orth, the mean length of a full-term, sound child is 
between fifty and fifty-one centimetres, the male being slightly longer 
than the female. The average weight of a full-term boy at birth is 
thirty-six hundred grammes, that of a girl thirty-two hundred and 
fifty grammes. For the last five lunar months of fetal life, if the 
height expressed in centimetres be divided by five, the approximate age 
of the child in lunar months will be obtained. For example, if the 
child measures thirty-five centimetres, we divide this by five, and we 
have seven, which is the number of months which the child has passed 
in ittero. The fetal age of the child in the first five months about 
equals the square root of the height expressed in centimetres. For 
example, if the height is sixteen centimetres, the child is four lunar 
months old. 

In terms of the English system the length of the new-born child 
is twenty inches, which divided by two will give approximately the 
number of lunar months the child has passed in ntero. 

According to Hirst, the following are the dimensions of a full- 
term, healthy child : Length of hair, from two to three centimetres ; 
anterior fontanel, from two to two and one-half centimetres ; occipito- 
frontal circumference, thirty-four and one-half centimetres ; occipito- 
frontal diameter, eleven and three-fourths centimetres ; occipitomental 
diameter, thirteen and one-half centimetres; bisacromial diameter, 
twelve centimetres; intertrochanteric diameter, nine or ten centi- 
metres. 

Lambinon 1 gives the following figures, obtained at the Liege Ma- 
ternity, as to the weight of the placenta in cases of miscarriage. The 
average weight of the placenta at six weeks was 20 grammes (about 5 
drachms) ; at ninety days, 67 grammes (17% drachms) ; at one hun- 
dred and twenty days, in grammes (28% drachms) ; at one hundred 
and sixty-five days, 262 grammes (67% drachms) ; and at two hundred 
and thirty-five days, 330 grammes (8514 drachms). 

Nauwerck gives the following measurements and weights of the 
healthy infant at full time: Average length, from fifty to fifty-one 
centimetres (boys generally larger than girls) ; maximal length, fifty- 



1 De la determination de I'age du foetus d'apres le poids du placenta dans les cas 
de fausse couche. Paris, 1898. 



WEIGHTS AND MEASURES 



269 



eight centimetres ; minimal length, forty-eight centimetres ; average 
weight (v. Hecker), thirty-two hundred and seventy-five grammes 
(boys thirty-three hundred and ten grammes, girls thirty-two hundred 
and thirty grammes) ; maximal weight, fifty-five hundred grammes; 
minimal weight, twenty-five hundred grammes. 

Weight of the different organs and measurements of various parts : 

Brain 380 grammes ( Bischoff ) . 

Brain 348 grammes ( Meynert) . 

Thymus 14 grammes (Friedleben). 

Heart 20.6 grammes (Thoma). 

Lungs 58 grammes. 

Width of the large fontanel 2-2.5 centimetres. 

Head : circumference 34.5 centimetres'. 

Occipitofrontal diameter 11. 5 centimetres. 

Biparietal diameter 9.0 centimetres. 

Bitemporal diameter 8.0 centimetres. 

Occipitomental diameter 13.5 centimetres. 

Trachelobregmatic diameter 9.5 centimetres. 

Spleen 11. 1 grammes. 

Kidneys (together) 23.6 grammes (Thoma). 

Testicles 0.8 gramme. 

Liver 118 grammes. 

The rule 1 that a child has usually attained double its birth weight 
at the fifth month and triple at from the twelfth to the fourteenth 
month is convenient and useful in estimating an infant's probable age. 

III. Table of approximate weight of the internal organs : 2 



Adult, New-born, 

grammes, grammes. 

Brain 1397 385 

Heart 304 24 

Lungs . . 1172 58 

Liver 1612 118 

Pancreas 201 11.1 

Right kidney 141 



Adult, 



New-born, 



grammes, grammes. 

Left kidney 150 

Both kidneys 299 23.6 

Testicles 48 0.8 

Muscles 29,880 625 

Skeleton 11,560 445 



IV. The body weight by percentage 



Adult, New-born, 

per cent. per cent. 

Heart - 0.52 0.89 

Lungs 2.01 2.16 

Stomach and alimen- 
tary canal 2.34 2.53 

Pancreas 0.346 0.41 



Adult, New-born J 

per cent. per cent. 

Liver 2.77 4.39 

Brain 2.37 14.34 

Thymus gland 0.0086 0.54 

Skeleton 15-35 16.70 

Muscles 43-09 23.40 



1 Graham, Archives of Pediatrics, January, 1899. 

2 Tables are from Vierordt, quoted by Ziegler, 7th German ed., vol. i. p. 181. 



270 



POST-MORTEM EXAMINATIONS 



In measuring an organ its length, breadth, and thickness may 
often be more quickly and accurately ascertained by thrusting the steel 
rule through it than in any other manner. 

THE SKULL AND ITS CONTENTS. 

Shape. — Even in members of the same race the form of the skull 
is subject to marked variations, and these are still greater when indi- 
viduals of different races are compared. The characteristic measure- 
ments of the cranium are its length, height, and breadth. The cephalic 
index is the ratio of its length (taken as one hundred units) to its 
breadth. The altitudinal index is the ratio of its length to its height. 
The accepted horizontal plane is that passing through the upper edges 
of the external auditory meatus and the lower orbital margin. 

According to the variations of the cephalic index, we distinguish 
the dolichocephalic (index less than 75) and the br achy cephalic (index 
more than 80) types. Intermediate forms are called mesocephalic. 
If the ratio of the breadth to the height is less than 70, the skull is 
platycephalic; if between 70 and 75, or tho cephalic; if above 75, hypsi- 
ccphalic. The character of the facial profile is indicated by the facial 
angle of Camper, — namely, the angle between a line on the level of 
the external auditory meatus and the floor of the nasal cavity and a 
line touching the middle of the forehead and the anterior portion of 
the alveolar process of the superior maxilla. If this angle be 80 de- 
grees or more, the skull is called orthognathous; if it is between 80 
degrees and 65 degrees, prognathous (Gegenbaur). 

Pathological types of skull are due in part to premature synostosis. 
Among them we distinguish the hydrocephalic type (from dropsy of 
the ventricles), the cephalonic (or big head), the microcephalic (or 
small head), the dolichocephalic (or long head), the spheno cephalic 
(or wedge-shaped head, due to compensatory development of the ante- 
rior fontanel), the leptocephalic (or narrow head), the clinocephalic 
(or saddle-shaped head), the trigono cephalic (or triangular head, due 
to narrowing of the frontal bone from fetal synostosis of the frontal 
suture), the br achy cephalic (or short head), the pachycephalic (in 
which the bones of the cranium are thickened), the oxycephalic (or 
pointed head), the platycephalic (or flat head), the trochocephalic 
(or round head), and the plagiocephalic (or unsymmetrical oblique 
head). 1 

1 Ziegler's Text-Book of Special Pathological Anatomy, English Translation by 
MacAlister and Cattell, vol. i. pp. 206, 207. 



WEIGHTS AND MEASURES 27 1 

Weight. — The maximum weight of the adult male encephalon is 
about 2222 grammes, or 74 ounces, and the minimum is about 960 
grammes, or 34 ounces. The average is about 140G grammes, or 49.5 
ounces. The maximum weight of the adult female encephalon is about 
1585 grammes, or 56 ounces, and the minimum is 880 grammes, or 31 
ounces. The average is from 1230 to 1245 grammes, or from 43^ 
to 44 ounces. Thus it will be seen that the adult male brain is on an 
average four or five ounces, or about nine per cent., heavier than that 
of the female. See also American Medicine, May 17, 1902, p. 830. 

Table showing in grammes the mean weights of the brain at dif- 
ferent ages in the two sexes : 

Male. Female. 

Children stillborn at term 393 347 

Children born alive at term 330 283 

Under three months of age 493 45 1 

From three to six months 602 560 

From six to twelve months 776 727 

From one to two years 941 843 

From two to four years 1,095 99° 

From four to seven years 1 ,138 i, 135 

From seven to fourteen years 1,301 x , J 54 

From fourteen to twenty years i,374 1,244 

From twenty to thirty years i,333 i, 2 37 

From thirty to forty years 1,364 1,220 

From forty to fifty years 1,35* 1,212 

From fifty to sixty years i,343 1,220 

From sixty to seventy years I ,3 I 3 1,208 

From seventy to eighty years 1, 288 1, 168 

Over eighty years 1,283 I , I2 5 

By the above table it appears that the brain is relatively heavier 
between fourteen and twenty years of age than at any other period; 
but according to Broca, and also Peacock, the maximum is attained 
between the ages of twenty-five and thirty-five. 

Orth quotes Meynert, whose results were obtained from the inves- 
tigation of 157 cases in the Vienna insane asylum. He gives the mean 
weight of the brain, in men between the ages of twenty and sixty-nine 
years, as 1296 grammes; in women, 11 69 grammes. He says the 
maximal weight is attained during the fourth decade in men and the 
fifth decade in women. The average weight of the cerebrum is 10 18 
grammes in men and 917 grammes in women; of the brain stem, 143 
grammes in men and 129 grammes in women; of the cerebellum, 135 
grammes in men and 123 grammes in women. Weisbach found that 



272 



POST-MORTEM EXAMINATIONS 



in sane German- Austrians the brain weighed 13 14.5 grammes in men 
and 1179.52 grammes in women, while the cerebrum weighed 1154.97 
grammes in men and 1038.90 grammes in women, the cerebellum 
142.2 grammes in men and 125.56 grammes in women, and the pons 
17.33 grammes in men and 15.06 grammes in women. Bischoff found 
the weight of the pia and arachnoid to be from 25 to 40 grammes. 
Nauwerck quotes Vierordt, who found the mean weight of the brain 
in men within the ages of twenty and eighty years to be 1359 grammes, 
in women 1235 grammes. 

The weight of the encephalon relative to that of the body is subject 
to great variation, but may approximately be put down as 1 to 36.5 in 
the adult male and 1 to 35.2 or 1 to 36.46 in the female. These figures 
are based on observations upon persons dying from more or less pro- 
longed disease, but in the cases of a few individuals who died suddenly 
from disease or accident the average ratio was found to be 1 to 41. 
The proportion to body weight is much greater at birth than at any 
other period of extra-uterine life, being about 1 to 5.85 in the male 
and 1 to 6.5 in the female. 

The weight of the human cerebrum also bears a somewhat definite 
relation to the stature of the individual. The weight in ounces may be 
obtained for a male by dividing the height in inches by 1.6, and for 
a female by multiplying the quotient thus obtained by ff-. The weight 
in grammes may be obtained by multiplying the height in centimetres 
by 7 for a male, and the product again by ff for a female. Thus, 



Weight in ounces of the mean cerebrum . 



_ height in inches 
~~ i~6 

Weight in ounces of the mean female cerebrum = — - X 

Weight in grammes of the mean male cerebrum . . = height in centimetres X 7 

Weight in grammes of the mean female cerebrum = height in centimetres X 7 X 

These proportions are slightly deficient for the higher and ex- 
cessive for the lower statures. 

Dimensions. — The mean cubic capacity of the male cranium is 
1450 cubic centimetres; that of the female is 1300 cubic centimetres 
(Welcker). The length of the male brain is from 160 to 170 milli- 
metres, or from 6| to 6f inches, and that of the female brain is from 
150 to 160 millimetres, or from 6 to 6f inches. The greatest trans- 
verse diameter is 140 millimetres, or 5f inches, and the greatest ver- 



WEIGHTS AND MEASURES 



273 



tical diameter is 125 millimetres, or 5 inches. The volume is about 
1330 cubic centimetres, or 81 cubic inches. 

The specific gravity of the brain is from 1035 to 1040. 

THE HEART. 

Weight. — The mean weight of the heart in the adult male is about 
310 grammes, or 11 ounces; its proportion to the body weight is 1 to 
169. That of the adult female is about 255 grammes, or 9 ounces; 
proportion to body weight, 1 to 149. According to Krause, the pro- 
portion of the heart weight to the body weight is as 1 to 169 in men 
and as 1 to 162 in women. 

The weight of the heart increases with the body weight, but in 
a gradually decreasing ratio, until the seventieth year, when it begins 
to diminish. At birth it is about 24 grammes: proportion, 1 to 130 
(Quain). 

Dimensions. — The heart is generally of about the same size as the 
right fist of the individual. Its extreme length is about 125 milli- 
metres, or 5 inches ; width, 87 millimetres, or 3 inches ; thickness, 62 
millimetres, or 23/2 inches. The thickness of the wall of the right 
ventricle is from 2 to 3 millimetres, or Yt to Y% of an inch ; of the left 
ventricle, from 7 to 10 millimetres, or J4 to -§■ °^ an inch. Patho- 
logically these measurements may be increased threefold. 

Nauwerck and Orth quote Bizot as follows : The weight of the 
heart is 300 grammes in men and 250 grammes in women. The length 
in men is from 85 to 90 millimetres, in women from 80 to 85 milli- 
metres; the breadth in men is from 92 to 105 millimetres, in women 
from 85 to 92 millimetres; the thickness in men is from 35 to 36 milli- 
metres, in women from 30 to 35 millimetres. The thickness of the 
right ventricle without the trabeculse is from 2 to 3 millimetres in men 
and slightly less in women; the left ventricle is from 7 to 10 milli- 
metres thick. 

The dimensions of the orifices of the heart are shown in the fol- 
lowing tabular statement. 

r\-r\&^^ r,;, mDfor Circumference. Area. 

Orifices. . Diameter. Male Female. Male. Female. 

Aortic 24 to 25 mm., or 81 mm. 76 mm. 530 sq. mm. 452 sq. mm. 

0.9 to 1 in. 
Mitral 30 to 35 mm., or 103 mm. 101 mm. 855 sq. mm. 804 sq. mm. 

1.2 to 1.4 in. 
Pulmonary 27 to 30 mm., or 91 mm. 89 mm. 660 sq. mm. 615 sq. mm. 

1.1 to 1.2 in. 
Tricuspid 37 to 45 mm., or 122 mm. 115 mm. 1194 sq. mm. 1017 sq. mm. 

1.5 to 1.8 in. 



2J4 POST-MORTEM EXAMINATIONS 

Volume. — In the new-born this is about 22 cubic centimetres, 
which is increased to 250 centimetres at twenty years and about 280 
centimetres at fifty years, after which it gradually decreases. Up to 
the age of puberty it is about the same in both sexes, but after that it 
is from twenty-five to thirty centimetres larger in the male. Because 
of obvious difficulties, these figures can only be regarded as approxi- 
mate. 

THE LUNGS. 

Weight. — Obviously the lungs are subject to great variation in 
weight, depending upon the amount of blood or other liquid and of 
air in their cavities. Their combined weight ranges from 850 to 1370 
grammes, or from 30 to 48 ounces, the average being from 1020 to 
1 190 grammes, or from 36 to 42 ounces (1300 grammes in the male 
and 1023 grammes in the female. — Krause). The right is generally 
2 ounces heavier than the left. The weight of the right lung is from 
360 to 570 grammes: that of the left lung, from 325 to 480 grammes 
(Schmaus quoted by Nauwerck). The lungs are absolutely heavier 
in the male and also appear to be heavier in proportion to the body 
weight. 

Dimensions. — The extreme length of the right lung in the male 
is 271 millimetres, or rof inches, and that of the left is 298 milli- 
metres, or 12 inches: and in the female. 216 millimetres, or 8f inches, 
and 230 millimetres, or 9-5- inches, respectively. The extreme outer 
and posterior diameters in the male are, of the right, 203 millimetres, 
or 8 J /g inches, and of the left. 176 millimetres, or 7 inches; and in 
the female, 176 millimetres, or 7 inches, and 162 millimetres, or 6^2 
inches, respectively. The transverse diameter at the base is, in the 
male, 135 millimetres, or 5I inches, for the right, and 129 milli- 
metres, or 5 1 6 inches, for the left. In the female the measurements 
are 122 millimetres, or 4]/$ inches, and 108 millimetres, or 4 J- inches, 
respectively. (Krause, quoted by Vierordt.) 

The specific gravity of the healthy adult lung varies from 345 to 
746. When fully distended with air it is about 126. while that of the 
lung tissue itself, entirely deprived of air. is about 1056. 

THE LIVER. 

Weight. — The liver weighs from 50 to 60 ounces in males, a little 
less in females. Its mean weight is 1600 grammes. — from a minimum 
of 1247 grammes to a maximum of 1981 grammes, — according to 



WEIGHTS AND MEASURES 275 

Vierordt, quoted by Nauwerck. In a four-months foetus it is about 
one-tenth of the body weight ; at birth it is one-twentieth ; in the adult 
male it is one-fortieth ; in the adult female it is one-thirty-sixth. 

Dimensions. — (Ouain.) The transA^erse diameter is from 150 to 
200 millimetres, or 6 to 8 inches; vertical diameter, from 125 to 175 
millimetres, or 5 to 7 inches; and anteroposterior, from 100 to 150 
millimetres, or 4 to 6 inches. 

(Morris.) Transverse, from 175 to 250 millimetres, or 7 to 10 
inches; vertical, from 150 to 175 millimetres, or 6 to 7 inches; and 
anteroposterior, from 75 to 150 millimetres, or 3 to 6 inches. 

(Gray.) Transverse, from 250 to 300 millimetres, or 10 to 12 
inches; vertical, 75 millimetres, or 3 inches; and anteroposterior, 
from 150 to 175 millimetres, or 6 to 7 inches. 

Right lobe, from 18 to 20 centimetres. Left lobe, from 8 to 10 
centimetres. Longitudinal diameter ; right, from 20 to 22 centi- 
metres ; left, 15 or 16 centimetres. 

According to Orth. the transverse diameter is from 25 to 30 centi- 
metres, that of the right lobe being from 18 to 20 centimetres and that 
of the left from 8 to 10 centimetres. The anteroposterior diameter 
averages from 19 to 21 centimetres, — from 20 to 22 centimetres for 
the right lobe and 15 or 16 centimetres for the left. The greatest ver- 
tical diameter is from 6 to 9 centimetres. 

Volume. — This varies from 1475 t0 J 638 cubic centimetres, or 
from 90 to 100 cubic inches. The mean volume is 1574 cubic centi- 
metres. 

The specific gravity is between 1050 and 1060, which in fatty de- 
generation may be reduced to 1030 or even less. 

Supernumerary livers may weigh an ounce or more. 

THE KIDNEYS. 

Weight. — Each kidney weighs from about 127.5 to 1 7° grammes, 
or 4^2 to 6 ounces, in the male, and from 113 to 156 grammes, 4 to 
$y 2 ounces, in the female. The left kidney is usually a little heavier 
than the right, — from 5 to 7 grammes heavier, according to Orth, who 
states that one kidney weighs about 1 50 grammes, while both kidneys 
after the removal of the connective tissue of the hilum weigh 320 
grammes in men and 293 grammes in women. At the end of the first 
year the kidneys together weigh 62 grammes. The ratio of the weight 
of the kidneys to the body weight is as 1 to 200. The mean proportion 



276 POST-MORTEM EXAMINATIONS 

of the weight of the heart to the weight of the kidneys between the 
ages of twenty and thirty-five years is as 1 to 1.1 (Thoma). 

Dimensions. — Length about 100 millimetres, 2^ inches; breadth 
and thickness, from 30 to 35 millimetres, 1^ to i/ 2 inches; or in the 
proportions of about 1 to y 2 to %. The left kidney is usually a little 
longer and narrower than the right. Nauwerck states that the kidneys 
are from 11 to 12 centimetres long, 5 or 6 centimetres wide, and 3 
or 4 centimetres thick. 

Specific Gravity. — About 1050. 

The following points serve to distinguish between the right and left 
kidneys. 

Right Kidney. Left Kidney. 

Impression from liver. No impression from spleen. 

Shorter and broader. Longer and narrower. 

From five to seven grammes lighter. About five to seven grammes heavier. 

The spermatic or ovarian vein empties The spermatic or ovarian vein empties 
into the inferior vena cava. into the renal. 

In both kidneys the posterior surface is the natter, the external 
border is convex, the internal border concave, and the upper portion is 
more expanded than the lower. At the hilum the attachment of ves- 
sels and ureter is, from above downward, the body being in the erect 
posture, artery, vein, ureter ( AVU) ; and from before backward, vein, 
artery, ureter (VAU). Place the organ on the table, with its pos- 
terior surface down, the lower extremity (the ureter pointing down- 
ward) being towards the observer. The ureter is then behind and 
below the other vessels, and the hilum will be directed towards the 
side of the operator to which the kidney belongs, — i.e., towards the 
left hand if it is the left kidney, and towards the right hand if it is 
the right kidney. 

SUPRARENAL BODIES. 

Weight. — Each suprarenal weighs about 4 grammes, or 1 drachm, 
the left being slightly the heavier. They are nearly as large at birth as 
in adult life. Orth gives the weight in adults as from 4.8 to 7.3 
grammes. 

Dimensions. — Vertical length is from 30 to 50 millimetres, or ij4 
to 2 inches; breadth, from side to side, about 30 millimetres, ij4 
inches ; thickness, from 5 to 6 millimetres, \ to ]/^ inch. Nauwerck 
states that the mean diameters are from 4 to 5 centimetres, 2.5 to 3.5 
centimetres, and 0.5 centimetre. 



WEIGHTS AND MEASURES 



^77 



THE SPLEEN. 

II 'eight. — This organ varies within wide limits in both size and 
weight. Ordinarily its weight is between 100 and 300 grammes, or 
3^2 and 10 ounces, with the average at about 170 grammes, or 6 
ounces. In intermittent and some other fevers it may weigh 18 or 20 
pounds. Orth states that the normal weight varies between 150 and 
250 grammes. Its weight in proportion to the body weight is at birth 
about 1 to 350; in the adult, 1 to from 320 to 400; and in old age, 
1 to 700. 

Dimensions. — Generally the spleen is from 125 to 150 millimetres, 
or 5 to 6 inches, in length; from 75 to 90 millimetres, or 3 to 3^2 
inches, in breadth; and from 25 to 40 millimetres, or 1 to 1J/2 inches, 
in thickness. According to Orth, the length is from 12 to 14 centi- 
metres, the breadth 8 or 9 centimetres, and the thickness 3 or 4 centi- 
metres. 

Volume. — This does not usually exceed from 200 to 300 cubic 
centimetres, or 12 to 18 cubic inches. Orth gives 221.5 cubic centi- 
metres as the mean volume. 

THE PANCREAS. 

Weight.* — The weight is very variable, — from 30 to 100 grammes, 
or 2 to 3^ ounces, and may even be 170 grammes, or 6 ounces; in 
adults, from 90 to 120 grammes (Orth). 

Dimensions. — From 120 to 150 millimetres, or 5 to 6 inches, in 
length; and from 12 to 25 millimetres, or / 2 to 1 inch, in thickness. 
Length 23 centimetres, breadth 4.5 centimetres, thickness 3.8 centi- 
metres (Orth). 

Specific Gravity. — 1046. 

THE THYMUS GLAND. 

Weight. — At birth this gland weighs about half an ounce. In 
twenty adult cases it was found to average 5 grammes (Quain). 
Nauwerck quotes Friedleben, who says that the thymus weighs at 
birth 14 grammes and at nine months of age 20 grammes. Up to 
the second year it weighs a little more than 6 grammes, and from 
the third to the fourteenth year a little less than 26 grammes. 

Dimensions. — At birth the length is about 60 millimetres, or 2 
inches; width, 37 millimetres, or i}4 inches; and thickness, from 6 



278 POST-MORTEM EXAMINATIONS 

to 8 millimetres, or J4 to Vs °f an inch. From birth to the ninth 
month the length is 5.91 centimetres (Friedleben) ; from the ninth 
month to the second year, 6.96 centimetres, and from the third to the 
fourteenth year, 8.44 centimetres. The breadth across the middle is 
from 2.7 to 4.1 centimetres; above and below, from 0.7 to 0.9 centi- 
metre (Nauwerck). 

THE THYROID GLAND. 

Weight. — From 28 to 56 grammes, or 1 to 2 ounces, being larger 
in the female. Orth gives the weight as from 30 to 60 grammes. 

Dimensions. — Each lateral lobe is about 50 millimetres, or 2 inches, 
in length; from 18 to 30 millimetres, or % inch to ij4 inches, in 
breadth; and from 18 to 25 millimetres, or y± to 1 inch, in thickness. 
The right lobe is usually the larger. The isthmus is nearly 12 milli- 
metres, or y 2 inch, in breadth, and from 6 to 18 millimetres, or % to 
J4 inch, in depth. According to Orth, each lateral lobe is from 5 to 7 
centimetres long, from 3 to 4 centimetres broad, and from 1.5 to 2.5 
centimetres thick. 

THE TESTES. 

Weight. — Each testicle weighs from 18 to 25 grammes, or 6 to 8 
drachms, the left being slightly the heavier. Orth gives 18 to 26 
grammes as the weight; Nauwerck says the testicle and epididymis 
weigh from 15 to 24.5 grammes. 

Dimensions. — Length, about 37 millimetres, or iy> inches; 
breadth, anteroposterior, 30 millimetres, or 1 J4 inches; thickness, 
from side to side, 24 millimetres, or 1 inch. 



THE OVARIES. 

Weight. — From 4 to 8 grammes, or 1 to 2 drachms. Orth gives 
5 to 7 for the weight, and Nauwerck quotes Puech, who puts the mean 
weight at 7.0 (from 5 to 10) grammes. 

Dimensions. — Length, usually about 37 millimetres, or 1^2 inches; 
breadth, 18 millimetres, or % inch; thickness, 12 millimetres, or y 2 
inch. The right is usually a little larger than the left. According to 
Orth, the ovary is from 2.5 to 5 centimetres long, from 2 to 3 centi- 
metres broad, and from 7 to 12 millimetres thick. Nauwerck gives 
the following dimensions, quoted from Puech. 



WEIGHTS AND MEASURES 279 

Length, maidens from 4.1 to 5.2 centimetres. 

Length, women from 2.7 to 4.1 centimetres. 

Breadth, maidens from 2.0 to 2.7 centimetres. 

Breadth, women from 1.4 to 1.6 centimetres. 

Thickness, maidens from 1.0 to 1.1 centimetres. 

Thickness, women from 0.7 to 0.9 centimetre. 

THE UTERUS. 

Weight. — Generally from 28 to 42 grammes, or 1 to 1^ ounces 
Orth quotes Huschke, who gives from 33 to 41 grammes as the weight 
of the uterus in virgins and 105 to 120 grammes as the weight in 
multiparas Nauwerck gives 33 to 41 grammes as the weight in vir- 
gins, and 102 to 1 17 grammes as the weight in multiparas 

Dimensions. — Length, about 75 millimetres, or 3 inches; breadth, 
50 millimetres, or 2 inches; thickness, nearly 25 millimetres, or 1 inch. 
The virgin uterus is from 5.5 to 8 centimetres long, from 3.5 to 4 
centimetres broad, and from 2 to 2.5 centimetres thick; in multiparas 
the womb is from 9 to 9.5 centimetres long, from 5.5 to 6 centimetres 
broad, and from 3 to 3.5 centimetres thick. The walls of the virgin 
uterus are from 1 to 1.5 centimetres thick; of the cervix, from 0.7 to 
0.8 centimetre thick. In multiparas the uterine walls may be as thick 
as 2 centimetres, and the cervix is from 0.8 to 0.9 centimetre thick. 
(Orth.) 

The length of the virgin uterus, from the fundus to the external os, 
is from 7.8 to 8.1 centimetres and the breadth of the fundus is from 3.4 
to 4.5 centimetres; the thickness below the fundus is from 1.8 to 2.7 
centimetres; the length of the cervix is from 2.9 to 3.4 centimetres; 
the breadth of the cervix is 2.5 centimetres ; the thickness of the cervix 
is from 1.6 to 2 centimetres. In multiparas the length of the uterus is 
from 8.7 to 9.4 centimetres, the breadth 5.4 to 6.1, and the thickness 
3.2 to 3.6 centimetres. The length of the uterine cavity in virgins is 
5.2 centimetres, after the menopause 5.6 centimetres; in multiparas 5.7 
centimetres, after the menopause 6.2 centimetres. (Nauwerck.) 

THE PROSTATE. 

Weight. — Average, from 18 to 20 grammes, or /\.y 2 to 4^4 
drachms. Orth gives 17 to 18.5 grammes as the weight; and Nau- 
werck quotes Krause and Bischoff, who give 19 to 20.5 grammes as 
the weight. 

Dimensions. — Transverse diameter, about 7,7 millimetres, or i T / 2 
inches ; vertical, 30 millimetres, or 1 % inches ; anteroposterior, nearly 



2 8o POST-MORTEM EXAMINATIONS 

1 8 millimetres, or y± inch. These measurements are subject to great 
variation, according to the fulness of the rectum and bladder. Ac- 
cording to Orth, the prostate measures from 32 to 45 millimetres in 
its transverse diameter, 14 to 22 millimetres in thickness, and 25 to 35 
millimetres from apex to base. Nauwerck gives the following dimen- 
sions: Transverse diameter (breadth), from 3.2 to 4.7 centimetres 
(mean, 4.5 centimetres) ; sagittal diameter (thickness), from 1.4 to 
2.3 centimetres (mean, 2 centimetres) ; from apex to base (height), 
from 2.3 to 3.4 (mean, 2.y centimetres). 

Embryos 1 about one millimetre long are about twelve days old ; 
2.5 mm., fourteen days old; 4.5 mm., nineteen days old; seven mm., 
twenty-six days old; 11.5 mm., thirty- four days old; seventeen mm., 
forty-one days old. For all embryos from one to one hundred mm. 
long, multiply the length of the embryo from the vertex to the breech 
in millimetres by one hundred and extract the square root; the result 
will be the age in days. For embryos from one hundred to two hun- 
dred millimetres long, measure from vertex to breech; this length in 
millimetres will equal the age expressed in days. 

1 Mall, Bull. Johns Hopkins Hosp., vol. xiv., No. 143, February, 1903 ; abstracted 
in Medicine, vol. 9, No. 3, 1903, p. 240. 



CHAPTER XXVI 

COMPARATIVE POSTMORTEMS 1 

The great number, importance, and variety of diseases which 
human beings may contract from the lower animals are more and more 
coming to be recognized. Our domestic animals suffer from nearly 
all the contagious maladies found in man, and impart to him various 
disorders from which he would otherwise be exempt, such as glanders, 
actinomycosis, anthrax, hydrophobia, foot-and-mouth disease, echino- 
coccus cysts, trypanosomatosis, etc. The rat disseminates bubonic 
plague, the mosquito malaria, yellow fever, and dengue, and the pig 
trichinosis, and were it not for the rat, the mosquito, and the pig these 
diseases would probably cease to exist. 

Many of the suggestions made in the previous chapters apply with 
equal force to the performance of necropsies upon the lower animals. 
Such comparative examinations are of two distinct classes, — veterinary 
postmortems and laboratory postmortems. For laboratory study small 
animals, such as the guinea-pig. rabbit, mouse, and rat. are generally 
chosen, while in veterinary investigation the subject is usually a dog, 
a horse, a cow, or a cat. So intense is the interest now taken in com- 
parative pathology that all classes of animals come to section, even 
reptiles (especially snakes) receiving no small amount of attention. 

Instruments. — In post-mortem examinations of the large domes- 
tic animals (cow, horse, mule, etc.) the instruments used must neces- 
sarily be larger than those employed in human autopsies. The 
following is a partial list. ( I ) Large butcher's knife, to expose the 
thorax and abdomen and remove the skin; (2) large cleaver; (3) 
large butcher's saw, to open the thoracic and cranial cavities, expose 
the nasal septum, etc.; (4) large chisel, to remove the cord; (5) 
hammer, for the same purpose; (6) bone-forceps (costotome) ; (7) 
enterotome ; ' ( 8 ) scissors; (9) brain-knife; (10) dissecting forceps ; 
(11) large needle; (12) strong twine, etc. 

Utensils. — Buckets, pitchers, large and small enamelled plates, 

. * Much of the material and all the illustrations except Figs. 163 and 164 in this 
chapter are taken from Kitt's Lehrbuch der pathologischen Anatomie der Haus- 
thiere. 1900, vol. ii. pp. 1-54. 

2S1 



282 POST-MORTEM EXAMINATIONS 

sponges, soap, towels, and disinfectants, and green soap or lysol are 
especially useful. 

Clothing. — An operator's apron may be drawn over the clothes 
or an ordinary rain-coat worn, but a special suit for operating is better. 

General Suggestions. — In many cases the necropsy must be 
made at the place where death occurred, be this in the fields, stable, 
slaughter-house, or veterinary morgue. The procedure will vary with 
the conditions and conveniences, but the end in view should be care- 
fully considered and certain general rules observed. If the animal is 
alive, the method of killing to prepare for the desired investigation 
should be one that will not injure the organs involved. In cerebral 
trouble the animal should not be killed by a blow upon the head, but 
by poison or chloroform ; in inflammatory conditions all loss of blood 
should be avoided; if the trouble is in the digestive system, no poison 
should be used; and in pulmonary affections the animal must not be 
shot through the heart (Csokor). 

The skin, extremities, joints, excessive functionation of the mam- 
mary gland, and the frequency of parasitic lesions in the muscular 
tissue are so often subject to pathological conditions that they present 
a rich field in post-mortem examinations of lower animals. Malfor- 
mations are also quite common. 

There has recently taken place an interesting discussion as to Koch's 
statements that human tuberculosis differs from bovine and cannot be 
transmitted to cattle,- and that man does not, except possibly in the 
rarest instances, contract tuberculosis from the cow. Both sides admit, 
however, that there is a great difference between the virulence of 
various forms of the tubercle bacilli. From a careful study of the work 
of Koch, Schutz, Ravenel, Jong, Chippolina, and others, it would seem 
that bovine and human tuberculosis may be intercommunicated and 
cannot always be distinguished the one from the other, and that man 
may, and children often do, contract tuberculosis from the cow. In 
Switzerland and in this country the writer has been struck with the 
freedom from tuberculosis of districts in which cow's milk is not used. 

Operative Technic. — In opening the cadaver the normal position 
of the intestines should be retained as far as possible, and they should 
be carefully examined to see that they are uninjured and are suffi- 
ciently exposed. Horses, large and small ruminants, and the larger 
swine are usually placed upon the left side of the body so that the right 
side may be opened. A dorsal position may be chosen for dogs and 



COMPARATIVE POSTMORTEMS 



283 



cats, and even for swine or larger animals if sufficient assistance be 
present, as it gives a better view of the abdominal cavity. 

The postmortem is begun by removing the hide, which has a market 
value and must not be injured. As scalpels and straight-edged knives 
are apt to button-hole the skin, a butcher-knife with rough cutting edge 
is to be preferred. Beginning at the angle of the chin a longitudinal 
incision is made down the median line the whole length of the body, 
avoiding the udder, prepuce, and scrotum, and the navel in the case 
of young animals. A transverse incision is made perpendicular to 
the first along the median surface of the foreleg and the skin is drawn 
back from the edges up over the dorsal surface. A similar cut is made 
upon the median surface of the thigh and leg down to the tuberosity of 
the os calcis. On both the limbs and the body the hair-seams will serve 
as a useful guide for the knife. A circular incision is made around the 
head from angle to angle at the lips. If the head is to be preserved, 
as in the case of a deer, the circular incision is made at the manubrium. 
The skin may be detached either with the hands or with the handle of 
a chisel. 

Removal of the Extremities. — After the animal has been 
skinned, it is placed on its side, and the uppermost limbs are removed 
in order to secure more room for subsequent manipulation. First the 
foreleg is held up by an assistant and the shoulder- joint disarticulated. 
The mass of common muscle is cut through in the median portion by 
a butcher-knife grasped firmly by the whole hand. During the exsec- 
tion the extremity should be constantly raised by an assistant and the 
blade of the knife should be held somewhat towards the thorax so as to 
cut obliquely to the ribs. 

To remove the posterior extremity make a deep circular incision 
through the hip muscles, beginning with the broad crural fascia and 
above the large trochanter, passing up over and through the muscula- 
ture of the croup and downward and outward into the ischiatic fossa, 
but not behind the tuberosity of the ischium; raise the foot; cut 
through the adductors in a line with the acetabulum, open its capsular 
ligament, and section the round ligament. The incision of the capsular 
ligament is accompanied by a snapping sound, due to the entrance of 
air into the joint. The limb can now be drawn backward, the remain- 
ing fascia and muscles sectioned, and the whole removed. 

Exposure of the Abdominal Cavity. — Before opening the ab- 
dominal cavity of a filly the udder should be entirely removed from the 



284 POST-MORTEM EXAMINATIONS • 

abdominal wall, and in geldings and stallions the scrotum and the 
penis should be isolated and thrown back. It should be remembered 
that in herbivora meteorism occurs soon after death, so that the intes- 
tines are pressed up closely against the abdominal wall and may easily 
be injured. 

The operator should stand in the space between the remaining 
extremities with his face towards the breast of the animal. An incision 
is made through the median line of the body, beginning with the 
ensiform cartilage of the sternum, extending as far as the pubic region, 
cutting through the muscles and fascia only and not injuring the peri- 
toneum. This will not be difficult if the blade of the knife be held 
flat and the ball of the thumb placed near the edge and close to the 
point. As the peritoneum is carefully torn through with the ringers, 
the exit of gases, liquids, or abnormal contents of the abdominal cavity 
should be noted, as well as the position of the intestines. The index 
and middle finger are then separated so as to form a V-shaped space, 
in which the knife is placed and its point thrust through the abdominal 
wall along the line of the linea alba, the fingers following. At the 
posterior end of the longitudinal incision a second incision is made, 
perpendicular to the first, extending from the pubic region to the 
lumbar. The right upper half of the abdominal wall is held up by its 
edges with the left hand. The assistant pulls on the lower ribs in order 
to make the abdomen tense, and its covering is cut through with sawing 
strokes of the knife as far as the costal processes. The knife is so 
held by the whole hand that the point is shoved away from the operator 
towards the lumbar region and the lower part of the blade is used 
instead of the point. 

We have now a large anterior and a small posterior segment of the 
abdominal wall. They may easily be drawn back and a view of the 
abdominal organs obtained. The ribs of the horse extend so low down 
that a sufficiently extensive view for pathological purposes cannot be 
obtained; therefore, before removing the abdominal contents the tho- 
racic cavity is exposed. Then, by thrusting the hand well up under 
the lower ribs, we notice whether the diaphragm is tightly vaulted 
forward or is more or less relaxed. 

Exposure of the Thoracic Cavity. — A small incision is made 
between two of the true ribs and note is taken whether or not air enters 
the thoracic cavity and the diaphragm becomes relaxed. If the ab- 
dominal examination showed the diaphragm drawn down posteriorly, 



COMPARATIVE POSTMORTEMS 



285 



the incision should receive special attention; instead of air entering, 
there may be an exit of gas from the pleural cavity, indicating some 
essentially pathological condition. 

The direction for cutting the ribs is through the costal angles fol- 
lowing the course of the iliocostal muscle. An incision is made 



Temporomaxillary articulation 




Fig. 154.— Equine viscera, the animal resting on its right side, the anterior and posterior left limbs 
having been removed,, and the abdominal, thoracic, oral, and pharyngeal cavities opened. The double 
lines show the places in the intestines which are to be tied previous to being cut. 



between the true ribs and the blade of the saw introduced, an assistant 
making the breast tense while the sawing is done ; very little pressure 
should be used or the bone will splinter. When the ribs have been 
sawed through, they are turned over towards the median line and 
removed by severing the costal cartilages. The situation of the organs 
and the pathological contents should be carefully noted. (Fig. 154.) 



286 



POST-MORTEM EXAMINATIONS 



Removal of the Abdominal Contents in the Right Lateral 
Position. — After exposing the abdominal cavity by the longitudinal 
and transverse incisions, pull the two left coils of the colon either up 
over the thorax or out across the body on the right side, so that the 
sigmoid flexure looks towards the head or lies on the ground and the 
body and tip of the caecum come into view. Spread the mesorectum 
out over the left flank and pelvic region. Stroke back the faeces, doubly 

Duodenum 



Rectum 




Fig. 155. — Further dissection of animal seen in Fig. 154.. Appearance of the parts after removal of the 

rectum, ileum, and jejunum. 



ligate the rectum at its entrance into the pelvis, and section. Cut away 
the mesorectum up to its origin at the rectoduodenal ligament, doubly 
ligate the rectum, section, and remove. 

The ileum is easily recognized by its thicker walls and its entrance 
into the caecum. Apply a double ligature, section, and, holding the 
intestine in the hand, cut away all the mesentery from the whole of 
the small intestine as far as the rectoduodenal ligament, divide this, 
doubly ligate the duodenum, and section. The junction of the colon 



COMPARATIVE POSTMORTEMS 287 

with the rectum is now exposed, — the so-called stomach-like or gas- 
troid dilatation, — under which lies the anterior root of the mesentery. 
Grasping the dilatation with the left hand (Fig. 155), pull it towards 
the caecum, and with the right hand work loose or cut partly away 
the connections between the gastroid dilatation and caecum and the 
omental sac, kidney, and pancreas. In this way better access to the 
portal vein and anterior root of the mesentery is obtained. With the 
ringers work through the cellular tissue surrounding the root of the 
mesentery, grasp it with the hand, and together with the portal vein 
cut it away close to the intestine, leaving as much of it as possible with 
the aorta. The colon and caecum are now drawn out of the cavity, all 
the remaining sections being easily torn or cut away, while the right 
branch of the pancreas which lies upon the caecum and the root of the 
mesentery must be carefully dissected away. Grasp the spleen, section 
the suspensory (gastrosplenic) ligament and the gastrosplenic omen- 
tum, and free the spleen from the stomach. Separate the branches of 
the pancreas from the larger blood-vessels and the kidneys, so that it 
hangs only by its body from the liver, and leave it in this position or, 
after examining its excretory duct, cut it away. Next remove the 
stomach and duodenum by cutting along the sigmoid curvature and the 
smaller curvature of the stomach and by sectioning the duodenorenal 
ligament, the hepatic and pancreatic ducts, the diaphragmatic and 
gastrohepatic ligaments, and the oesophagus, after pulling the latter 
down as far as possible from the diaphragm. Excision of the liver is 
an easy matter : section first the left lateral ligament, then the coronary 
and suspensory ligaments, the vena cava on the anterior surface of the 
liver, the right lateral portion of the coronary ligament, and the right 
hepatic and renal hepatic ligaments. 

Removal of the Abdominal Contents in the Left Lateral 
Position. — The rectum is sectioned at its entrance into the pelvis after 
pressing back the faeces with the fingers, applying a double ligature, 
and cutting between them. Seize the colon at its anterior curvature 
and pull it carefully out of the abdominal cavity as far as possible. 
The left folds' of the colon will fall out with very little assistance. 
(Fig. 156.) 

In the region of thejkidney will be seen the arch of the duodenum 
lying between the anterior and posterior roots of the mesentery and 
covered by the ribs. Cut through this arch and its mesentery, after 
applying a double ligature, and remove. The cellular tissue lying 



288 



POST-MORTEM EXAMINATIONS 



between the caecum and psoas muscle and the right kidney should be 
carefully worked loose and the pancreas separated from the caecum and 
the colon; this is done by tearing or cutting through the peritoneum 
covering the intestine and pancreas, getting the hand in under the 
pancreas, and working it loose. Beginning posteriorly, cut away the 
mesorectum from behind forward and any connections that may 
remain between the caecum and colon and the region of the kidney, 



Duodenum 



Iliac spinal column 




Root of the mesentery and portal vein 



Line for sawing ischio- 
pubic suture 



Fig. 156. — Further dissection of animal seen in Fig. 155. Appearance of the parts after removal of the 

large intestine. 



grasp as much as possible of the attachment of the mesentery, pull the 
intestine back away from the kidney, and section the root of the mesen- 
tery in front of the left hand, as far from the aorta as possible. With 
the exception of a small portion of the duodenum and the pelvic por- 
tion of the rectum the large and small intestines can be drawn out 
from the abdominal cavity by cutting or tearing away any attachments 
which may remain ; the operator stands alternately at the back and in 
front of the cadaver while removing these portions. 

Removal of the Kidneys, Stomach, Liver, and Spleen. — The 
removal of the kidneys leaves a freer field for the stomach, spleen, and 
liver. With the hand and fingers separate first the right and then the 
left kidney and the suprarenal capsules from the surrounding cellular 






COMPARATIVE POSTMORTEMS 289 

tissue. If the ureters and kidneys are intact the kidneys may at once 
be cut away together with their vessels. In case of any abnormalities 
they should be left hanging or a sufficient length of the ureters removed 
with them, together with the surrounding tissues, or they may remain 
attached to their ureters and placed in the pelvic region. 

The pancreas, spleen, and stomach are freed from the mesentery 
and sectioned. The assistant pulls on the right side of the diaphragm, 
and the inferior vena cava between it and the liver is cut through 
together with the oesophagus. The stomach is turned backward. The 
left and right hepatic ligaments are sectioned and all the three organs 
removed together in a mass. 

If the kidneys are left in place, the exenteration of the stomach, 
pancreas, and liver is more difficult and demands more caution, espe- 
cially if the animal has not been bled, because the field is obscured by 
blood and other impurities. Dissect away carefully the attachments 
of the right kidney to the suprarenal capsule and left branch of the 
pancreas, which lies deep down, covered by the branches of the mesen- 
teric arteries ; next the adrenals, then the fundus of the stomach from 
the crurse of the diaphragm, the suspensory ligament of the spleen, the 
splenorenal ligament, the right coronary and lateral ligaments of the 
liver, the hepatic renal ligament, the vena cava, with the falciform 
ligament, the oesophagus, and the left lateral and coronary ligaments 
of the liver. 

All these organs may be removed with the diaphragm, and, when 
there are adhesions to its posterior surface, this is the preferable 
method. The right lobe of the liver is first separated from the kidney ; 
the pancreas, spleen, and stomach are worked loose from the spinal 
column in the thorax; the posterior vena cava, the oesophagus, and 
the pulmonary attachments to the diaphragm are sectioned; the dia- 
phragm is freed from the thoracic wall by a circular excision, and the 
whole mass removed together. Finally, the aorta and the venae cavae 
with their branches are dissected off the spinal column from the dia- 
phragm to the pelvis. 

Exenteration in the Dorsal Position. — The body may be 
kept on its back by tying the feet to rings in the wall or to posts or 
poles. The extremities remain attached to the body, of course, and the 
broad muscles of the chest are only to be sufficiently incised to permit 
the anterior extremities to spring out a little and give access to the 
chest. If during the postmortem the extremities are released too 

19 



290 



POST-MORTEM EXAMINATIONS 



much, the body will fall to one side and make the exenteration more 
difficult. 

A longitudinal median incision is first made, then a bilateral trans- 
verse incision just posterior to the last ribs. The two left folds of the 
colon are drawn up over the right side of the body. The rectum is 
pulled out and spread over the left thigh and left ventral wall and the 
small intestine spread out over the region of the lower ribs. The ileum 
is found at its insertion into the caecum; it is thicker than the rest of 
the small intestine. It is tied off and sectioned, remaining in the hand 
after its mesentery is severed close up to the intestine. In this way the 
whole of the right lateral small intestine is removed from the abdomi- 
nal cavity and its mesentery left hanging by its root. When it passes 
into the duodenum between the two roots of the mesentery, doubly 
ligate and section. Doubly ligate and section the rectum at its entrance 
into the pelvis and again at its junction with the colon. 

The pancreas and first part of the duodenum are dissected away 
from the colon as in the first method. The roots of the mesentery and 
both the branches going to the large intestine are sectioned close up 
and the large intestine is removed. 

The stomach, spleen, etc., are removed as in the first method. 
Many operators prefer to excise the spleen and open the stomach along 
its greater curvature and the duodenum on its inferior surface, where- 
upon the pathway of the bile ducts may be determined and then the 
empty organs cut away. 

In the dorsal position the thoracic organs may be ablated by draw- 
ing them down towards the abdominal cavity. An incision is made 
between the rings of the trachea, two fingers are inserted, the trachea 
is grasped firmly, and the larger vessels are sectioned at the thoracic 
inlet ; the aorta is dissected away from the vertebrae and the posterior 
vena cava and oesophagus are sectioned. If it be desired to remove 
the thoracic viscera together with the trachea and cervical organs, the 
first rib is sawed through and excised; the cervical organs are then 
ablated according to the method to be described later. 

Vienna Method of Exenteration in the Left Lateral Posi- 
tion. — Csokor's quick method for removing the thoracic and abdomi- 
nal contents is as follows : The extremities are removed and the 
abdominal cavity is exposed by a longitudinal and a transverse incision 
as in the first method ; then the muscles of the back are cleared away 
and the sectioned abdominal wall is drawn up by a hook. With a 



COMPARATIVE POSTMORTEMS 2 CjI 

hatchet each rib is cut away from the spinal column and then from the 
breast-bone. The whole right wall of the thorax and abdomen is now 
drawn up over the head of the animal and the contents of both cavities 
are exposed. The right kidney is next removed and then the thoracic 
contents. After their ablation the cardiac end of the stomach is freed 
from the diaphragm and the duodenum is detached from the liver and 
its surroundings and excised together with the stomach and spleen. 
The abdominal aorta is separated from the spinal column, the rectum 
sectioned, and. all the intestines removed. The remaining organs are 
extirpated as in the other methods. This modification permits a very 
rapid necropsy, but the removal of the stomach and spleen is somewhat 
difficult. 

Discission of the Abdominal Contents. — To ascertain the 
macroscopical conditions of the abdominal contents it is necessary to 
make a few special incisions. The aorta is first examined and its dorsal 
wall slit up with the shears to expose the entrances into its branches, 
which are then cut open. On account of its great frequency, close 
search is to be made for an aneurism in the root of the mesentery. It 
is usually felt externally as a thick, cystic expansion. The branches to 
the small intestine — the duodenal, jejunal, and iliac arteries — are first 
given off from the short trunk of the artery lying in the root of the 
mesentery (the anterior mesenteric artery) ; next a large vessel, the 
ileocolic artery, which gives off a large branch, the inferior colic, and 
the ileocecal artery with its three branches. The superior colic comes 
off above the root of the mesentery on a level with the anterior rectal 
artery. After examining these branches slit the inferior and superior 
colic arteries in the mesocolon from their origin to the sigmoid flexure, 
If it seems necessary, examine the arteries of the small intestine in 
the same way and observe the mesenteric lymph-nodes. The bowel is 
opened with the shears along the line of the attachment of the mesen- 
tery so as to get a good view of Peyer's patches; keep the intestine 
lying flat, for if held up the contents run down into the lower portions, 
which is a nuisance. 

If the stomach is sufficiently full, cut it open with a knife along its 
greater curvature. If the duodenal portion remains with the stomach 
and liver, open it with the shears on its inferior surface in such a way 
that the termini of the hepatic and pancreatic ducts will not be injured 
and their patency may be demonstrated. Press and push along the 
course of the ducts so as to force out their contents. If there is any 



292 



POST-MORTEM EXAMINATIONS 



suspicion of abnormalities in these ducts, it is better to leave the 
stomach and duodenum in place and to open them before removal. 

Removal of the Thoracic Contents. — First carefully examine 
for sharp points of bone and excise them with cutting forceps. The 
pericardium should then be examined and worked free with the hands. 
The posterior vena cava is tied off and divided between the ligature 
and the diaphragm; the attachments of the liver and heart to the 
diaphragm are sectioned and an incision is made obliquely through the 
aorta down to the vertebral column. Thrust the finger into the pos- 
terior aorta, pull it up, and cut along the spinal column in the line of 
the vena azygos and the attachment of the longus colli. Now make 
an oblique section through the oesophagus, trachea, anterior aorta, and 
anterior vena cava along the line of the first rib, so that the thoracic 
organs may be removed. This avoids cutting the large veins, which 
bleed so freely as greatly to obstruct the view of the parts under ob- 
servation. 

Section of the Oral Cavity and Cervical Organs. — This is 
begun by removing the ramus of the lower jaw on one side. Cut the 
buccal parietes and the cheek at the angle of the lips up to the zygo- 
matic arch, between the molar teeth and the space between the lower 
jaw and the large maxillary swelling, dividing the masseter and saw- 
ing through the bones. The ramus of the jaw may now be worked up 
and down, its muscular connections severed by a knife introduced 
along its median surface, and an incision made between the parotid 
gland and the posterior border of the bone. The temporal muscle is 
cut through above the coronoid process and the ligaments and capsule 
of the joint are sectioned, the jaw being moved up and down to find 
the joint. After examining the local conditions, sever the left connec- 
tions of the tongue with the jaw and the soft palate; saw through 
both to the large branches of the hyoid bone. The larynx, trachea, 
and oesophagus are easily freed from their loose cellular tissue by 
cutting into the channel of the external jugular vein, between the 
longus colli muscle and the oesophagus, so that the thyroid gland is 
not injured. 

Dissection of the Thoracic and Cervical Organs. — In order 
more closely to inspect these organs, cut through the vault of the velum 
palati with the shears and continue down into the oesophagus, section- 
ing it dor sally. With the knife grasped firmly incise the larynx in the 
median dorsal line between the arytenoids. Pushing the oesophagus 



COMPARATIVE POSTMORTEMS 293 

aside, cut the posterior muscular ligament of the trachea with shears 
throughout its whole length and thrust the cartilages apart to get a 
good view of the interior. The lobes of the lungs are laid open with 
long, deep, bisecting strokes, and portions of each lobe are tested by 
throwing them into water to see whether they contain air and will 
float or will sink because of collapse or the presence of an exudate. 
The lymph-nodules around the roots of the bronchi must always be 
examined and sectioned. 

If the heart is hacked into or improperly opened, the distinctive 
appearance of any abnormality that may be present is destroyed, and 
these anomalies are of great importance to the whole organism. First 
make an incision into the right ventricle along the septum, insert the 
shears, and cut up into the pulmonalis. Holding the heart by this flap, 
lengthen the incisions towards the apex and the flap so as to get a 
better view of the ventricle. In the same way incise the left ventricle 
close to the septum and on the anterior surface ; insert a finger through 
the opening, find the entrance into the aorta, and with the shears cut 
down between the pulmonalis and the left auricle. It is true that in this 
way both semilunar valves are sectioned, but the auriculoventricular 
valves are spared and they are much more likely to present abnormali- 
ties than the semilunar. The size of the openings can be tested by 
inserting a finger, and the thickness of the walls measured, after which 
each auricle is cut through up into its vessels and a good view of their 
openings obtained. 

Exenteration of the Pelvis. — The removal of the pelvic organs 
is preceded by the previously described excision of the kidneys and 
ureters and in males by the exposure of the testicles and the external 
genitalia. The scrotum and penis were then turned back, and now 
their dorsal suspensory ligament and surroundings are divided as far 
as the ischiatic notch and all the flesh lying ventrad to the ischiatic 
suture is carefully cleaned away. The scrotum and the right and left 
inguinal canals are split open and the testicles together with the sper- 
matic vessels pulled up into the abdomen. It is especially necessary 
to cut the tendinous ligament which binds the corpora cavernosa to the 
ischium close to the bone, as well as the strong ischiopenile muscle. 
Two sections made by sawing will remove the right wall of the pelvis. 
The first one is made through the ischiopubic suture over the aceta- 
bulum to the iliac spinal column ; the second, through the thin part of 
the iliac bone, after cutting away the flesh that lies over the acetabulum 



»94 



POST-MORTEM EXAMINATIONS 



on the iliac column. By cutting the bone loose from the pelvic cellular 
tissue, it is easily pulled away. . 

The lateral wall of the pelvis being removed and a good view of 
the organs obtained, divide the connective tissue between the rectum 
and the superior pelvic wall ; free the uterus and ovaries, the neck of 
the bladder, the vagina, and the accessory sexual glands ; cut through 
the strong rectococcygei and the skin between the tail and the anus; 
and make a circular incision around the anus and the vulva (or the 
region of the penis). Remove the whole mass and section the organs 
dorsally. 

Exenteration of the Cranial Cavity. — To remove the head 
from the trunk we may either cut around the joint as if the throat were 
being cut or puncture the capsule ventrally and amputate between the 
condyles and the atlas. It is best to remove the whole of the lower 
jaw and let the skull, wrapped in a cloth, rest on its base and the molar 
teeth; it may then be held much more steadily than if the inferior 
maxillae had been left in place. The cranial attachments of the cer- 
vical and temporal muscles are next cut away and the soft parts re- 
moved from the roof of the skull. 

There are three lines for sectioning the cranium. The first lies 
transversely across the forehead about a thumb's breadth above the 
upper border of both superciliary ridges. The two other lines begin 
at the ends of the frontal incision, pass backward across the temples 
and petrous bones, and converge to the condyloid apophyses (Figs. 
157, 158). The first section can be made continuously, but the second 
and third will have to be done in several portions on account of the 
convexity of the cranium. 

The walls of the cranial vault are not equally thick, and care must 
be taken not to penetrate too deeply into the middle of the parietal 
bones and the squamous portion of the temporal bones. The frontal 
section passes through the frontal sinuses, so that there is very little 
danger here; and the same is true of the vertex and the pyramidal 
region above the condyles. The plates are not usually sawed clear 
through along the whole line, but the connections are broken with a 
chisel. Rest the palm of the hand upon the skull, grasp the chisel 
firmly near its edge so that it cannot enter too deeply, and tap gently 
with the hammer. When the bones are completely severed, pry the 
piece off by rocking the chisel backward and forward, first in the 
frontal and then in the condylar region. A sudden strong pull on the 



COMPARATIVE POSTMORTEMS 



295 



pericranium, grasping it at the edge of the frontal section, will gen- 
erally separate it from the other parts of the head; sometimes the 




Fig. 157. — Lines to guide the saw in ope 



le cephalic cavities of a horse. 



whole brain will come away at one jerk, together with the root of the 
skull. 

If the dura is too closely held or is adherent to the inner table of 




Fig. 158. — Lines of sawing for opening the cranial cavity of a horse. 



the skull, with the shears incise it in the line of the section in such a 
manner that the dorsal portion will come away with the calvarium. 



296 POST-MORTEM EXAMINATIONS 

Next excise the longitudinal and transverse blood-vessels in the duras. 
That part of the dura lying over the hemispheres is held up with 
forceps and cut with scissors so that it may be thrown back on both 
sides. The tentorium is sectioned anteriorly and posteriorly and re- 
moved. The membranous transverse septum which is torn away from 
the falx is incised laterally and pulled out from the transverse fissure, 
due attention being paid to its vascularity. 

Dissection of the Brain. — After examining the pia mater and 
the superficial surface of the brain, the hemispheres should be separated 
so as to expose the corpus callosum. The interior of the brain may 
either be examined now or after its removal. A horizontal incision is 
made immediately over the corpus callosum, starting at the median 
surface, and using preferably the so-called " brain-knife" or a long, 
flat scalpel. If the incision is not quite deep enough to enter the lateral 
ventricle, you will come first to the so-called " egg-shaped middle 
point" (centrum semiovale Vieussenii) ; press this gently with the 
finger and you will find a yielding point which, when incised, opens 
into the lateral ventricle. Follow the finger with the knife and slit 
open the roof anteriorly and posteriorly. Look for a collection of 
fluid, and examine the choroid plexus, corpora striata, horns of the 
ventricle, and median septum. This is seized in the middle, raised a 
little, sectioned transversely, and thrown back, the connections holding 
it to the peduncles being severed. Now carefully insert four fingers 
into the transverse fissure and raise the posterior lobes in order to 
expose the corpora quadrigemina, optic thalami, pineal gland, and 
middle choroid plexus. By separating the two thalami a little, you can 
divide the commissura mollis and see into the third ventricle. 

To remove the brain, support the skull upon the incisors in such 
a position that the condyles look upward and the brain would fall out 
if it were free. Into the space thus obtained between the medulla and 
the base of the skull, insert a finger, the closed scissors, or the handle 
of a scalpel, and sever the nerves one by one as they appear. The 
olfactory bulbs, which are unusually large in comparison with those 
of man, are worked out from the ethmoidal depressions by a circular 
thrusting motion of the handle of the scalpel. When they are all sepa- 
rated, the brain will fall into the waiting hand, which must steady it 
constantly or the olfactory bulbs would be torn away by its falling 
out too soon. 

After the brain is removed, the inferior surface is first examined, 



COMPARATIVE POSTMORTEMS 



297 



then, turning the brain over, the cerebellum is cut into halves. Expose 
the fourth ventricle and incise the floor longitudinally. With a thin- 
bladed knife cut radially to the cortex and transversely to the crurae, 
making numerous narrow incisions to detect the presence of any small 
hemorrhage or other lesion. 

Removal of the Spinal Cord. — This requires much time and 
labor when properly done, but is managed in various ways. But little 
time is spent in routine work when you have a butcher to assist you. 
The animal is suspended and the vertebrae are split off from their 
bodies by a hatchet; when this is cleverly done, the line of cleavage 
being kept a little to one side, the cord is but slightly injured. It is 
better, however, to proceed as follows : Saw off the ribs at their angles, 
separate the ilium from the sacrum, and clean off all the flesh. Laying 
the spine upon the table, begin at the pelvis and chisel off the vertebral 
arches, remembering that two chisels are necessary, one for each side, 
as the two instruments have different curves (Fig. 32). If an ordi- 
nary chisel is used, the arches should be partially sawed through to 
make their division easier. The hand holding the chisel supports itself 
on the spine, and the chisel is held as flat as possible while an assistant 
grasps the spinous processes and springs the arch apart. You may 
also expose the spinal canal ventrally by sawing through the vertebral 
bodies and arches on one side only. Section the nerves at their points 
of exit laterally to the intervertebral ganglia and lift out the cord 
enclosed in its membranes. Cut open the dura with the scissors and 
section the cord transversely with a sharp, thin knife. 

Exposure of the Accessory Sinuses. — To expose the nasal 
fossae saw the head in two, after removing the brain, a little to one 
side of the median line so as not to injure the septum on either side. 
These fossae may be sectioned transversely or their walls chiselled away 
to show the accessory sinuses. Csokor saws through the osseous struc- 
ture of the nose transversely from the level of the malar or lachrymal 
bone to the roots of the molars; a section is then made horizontally 
beginning at the anterior nares and joining at the first section (Fig. 
I 57)- O n raising this cap you have the maxillary, nasal, and frontal 
fossae well exposed. 

One or two long bones should be sawed through to judge of the 
condition of the bone marrow. 

Postmortems on Ruminants. — There are certain peculiarities 
in the skulls of ruminants which must be remembered when exposing 



298 



POST-MORTEM EXAMINATIONS 



the cranial cavity. It is only in very young animals that the cranial 
bones possess diploe, and in necropsies on hornless cattle the incisions 
are the same as for horses. On account of the prominent crests, which 
fall away very abruptly, and because a calf's head is somewhat rounder, 




Fig. 159. — Lines used in sawing in order to expose the cranial and nasal cavities in a ruminant. 

the sawing will have to be done in more segments, and great pains 
must be taken on account of the thinness of the bones. The older the 
animal the larger are the hollow places between the internal and ex- 
ternal plates; the diploe disappears and only a few crusts and plates 





%J*£^ 

Fig. 160. — Appearances of cranial cavity of a cow after removal of the bony vault. 

of bone interrupt the hollow spaces. The lateral and posterior portions 
of the skull are very prominent because of two large crests. The 
transverse section is nearly coincident with the posterior border of the 
superciliary ridges. The lateral sections are made in two segments, 



COMPARATIVE POSTMORTEMS 



299 



beginning at the ends of the transverse frontal incision and passing 
back over the temples to the foramen magnum. Clement has devised 
a better method (Figs. 159 and 160). First clear away all that part 
of the calvarium formed by the frontal eminence and the lateral 
depressions by sawing through the skull in a line passing from just in 
front of the horns obliquely backward and downward to the condyles 
or foramen magnum. After removing this plate of bone the whole of 
the posterior portion of the brain is exposed. Next make a transverse 
incision on a level with the superciliary ridges across the anterior end 
of the cranial cavity. Finally make two short longitudinal incisions, 
one on each side, about three centimetres from the median line; with 
mallet and chisel remove the oblong piece enclosed, and the whole 
brain is exposed. The curved horns of a sheep or a goat serve as 
convenient handles for removing the calvarium and may very well be 
left on, while the horns of neat cattle should be knocked off. 

Postmortems on Swine. — With the body lying on its left side, 
the right extremities are removed, the abdomen is exposed by longi- 
tudinal and transverse incisions, the diaphragm observed, and the 
lateral thoracic wall divided by cutting with the bone-shears or sawing 
through the angles of the ribs and severing the cartilages close to the 
sternum. To remove the abdominal contents, first find where the 
duodenum is attached to the rectum; sever the duodenorectal liga- 
ment, separate the pancreas from the mesentery, and section the duo- 
denum. The anterior root of the mesentery is loosened by working 
it free with the hand and pulling on it, then sectioned, the whole of the 
mesentery excised from before backward, and the rectum divided. 
Now cut away the spleen from the stomach, examine the opening of 
the bile duct, section it and the oesophagus, and separate the stomach 
from the diaphragm, leaving the liver freed from its suspensory liga- 
ment. The thoracic and cervical organs are removed as with other 
animals. 

In old quadrupeds the brain lies very deep, because of the immense 
air-spaces in the cranial bones which surround the brain on all sides 
except the temporal region. The transverse section is made a full 
thumb's breadth above -the superciliary ridges (the eyes being first 
removed) and the lateral sections run back to the occipital foramen. 
Instead of a transverse section we may make two oblique ones, begin- 
ning at the posterior border of the frontal process and joining each 
other and the lateral incisions in the anterior frontal region. 



3oo 



POST-MORTEM EXAMINATIONS 



Postmortems on Dogs and Cats. — The necropsy of a dog is 
easily and quickly made in either the dorsal or the left lateral position. 
The procedure is the same as for the horse, but it is not necessary 
to remove the extremities entirely or to take off the hide; simply cut 
through the muscles enough to allow the limbs to fall away a little 
and the body will be sufficiently steady. (Figs. 161, 162.) The thick- 




Fig. 161. — Postmortem of the dog. Double lines show places at which the intestines are to be tied; the 
dotted line indicates the direction for incising the mesentery. 



ening at the junction of the cartilages with the ribs is easily felt, the 
articulations are cut, and the sternum is pushed upward and forward 
after freeing the pericardium and the" pleura. Section the tracheal 



COMPARATIVE POSTMORTEMS 



301 



vessels and oesophagus at their entrance into the thorax and remove 
the thoracic organs. 

The removal of the abdominal contents of a dog is easy. Divide 
the rectum at the pelvis and the two mesenteric roots, and the abdomi- 
nal aorta and inferior vena cava behind the liver; thrust the hand in 
between the liver and the diaphragm, and with scissors section the 
suspensory ligament of the liver, the vena cava, and the oesophagus 
after it is pulled down from the diaphragm and tied off or compressed 
with the fingers. All the abdominal contents may now be removed 
together. Spread them out, examine each again, test the patency of 
the bile ducts, and straighten out the bowels. It is, however, better 
first to remove the intestine, which is sectioned through the duodenum 




jf 



Fig. 162. — The left ramus of the mandible has been removed and the tongue pulled outward and down- 
ward, thus exposing the oral and pharyngeal cavities in a dog. 

at the pancreas and through the rectum at the pelvis. You may next 
either remove the liver with the stomach, or after inspecting the bile 
ducts you may cut away the stomach from the oesophagus and duo- 
denum and then remove the liver. 

To expose the cranial cavity we have the same three lines as usual, 
the transverse section lying directly posterior to the rudimentary super- 
ciliary ridge, crossing the frontal sinuses and the anterior lobes of the 
brain. The anterior temporal and the parietal bones are not thick and 
contain diploe, so that the sawing must be carefully done. Since the 
petrous portion of the temporal bone has deep impressions upon its 
internal surface, in which convolutions of the cerebellum lie, and since 



302 POST-MORTEM EXAMINATIONS 

the bony processes project from the adjacent bones, great care must 
be taken not to tear the cerebellum. In small dogs with round heads 
the line for sectioning is more nearly a circular one. 

The postmortem of a cat is made in the same way. 

Post-mortem Examination of Birds. — Plug up the nostrils, 
mouth, and vent with cotton; make an incision from the point of the 
breast-bone, or a little above, backward to and through the anterior 
portion of the anus, leaving the uropygium (pope's nose). Loosen 
each leg to the knee (above the femur) by tearing the soft parts with 
your thumb and fingers, then cut with a knife until they meet around 
the pelvis at the rump. With your thumb-nail work the wings loose, 
hold the skin firmly, and, pressing your nail towards the body, cut off 
the wings at the elbow. Make a V-shaped slit with its apex towards 
the median line at the foramen magnum, running up towards the 
centre of the skull ; the brain is thus removed attached to the body and 
the skin is kept whole for taxidermic preservation. 

Post-mortem Records. — Kitt suggests the following scheme for 
the more intelligible recording of the findings in postmortems on the 
lower animals. 

RECORD OF NECROPSY. 

Species Gender Age Color of hair Owner 

Clinical history Treatment Mode of death Date of death 

Necropsy performed by Where performed Date 

Order of Persons present 

A. — External Examination. 

Position of the cadaver (on back, right or left side, hanging) 

Nutritional condition (weight) 

Removal or absence of parts 

Rigor mortis 

Condition of the skin and its appendages (the skin around the head, trunk, and 
extremities; the horns, claws, hoofs, ears, scrotum, prepuce, udder) 

The natural body openings and visible mucous membranes (the discharge of foam, 
fluids, and excrementa ; the color of the lips, nasal mucous membranes, con- 
junctivas, anal and vaginal mucosae) 

B. — Internal Examination. 

Facts obtained in removing the hide 

Condition of subcutaneous tissues, fat, lymph-nodules, vessels, extravasated blood, 
muscles, ligaments, tendons, and bones 

Abdominal and thoracic data 

Condition of diaphragm, position of organs, appearance of peritoneum, mediasti- 
nal and costal pleurae, and pericardium 



COMPARATIVE POSTMORTEMS 303 

The oral cavity, tongue, soft palate, salivary glands, pharynx, Eustachian tubes, 

oesophagus, retropharyngeal and laryngeal lymph-nodules 
The larynx, trachea, thyroid, and surroundings 
The lungs, bronchi, bronchial lymph-nodes 
The pericardial sac, heart, and thoracic vessels 
The liver and bile ducts, portal vein, and periportal lymph-nodules 
The spleen (capsule, pulp, trabecular, Malpighian bodies, and vessels) 
The stomach and crop 

The pancreas ; the large and small intestines 

The mesentery, omentum, posterior aorta and its branches, and vena cava 
The kidneys, adrenals, ureters, capsule and pelvis of the kidney, and its half 

section 
The urinary bladder, urethra, and accessory sexual glands 
The pelvic portion of the rectum 
The genitalia: uterus, vagina (pregnancy, foetal membranes, embryo), and the 

male genitals 
The cranial cavity and the brain : calvarium, sinuses, cavities at the base of the 

skull, dura, cerebral superficies, ventricles, gray and white matter 
The eyes; the middle and internal ears 

The fourth ventricle and the spinal cord with its membranes 
The nasal fossse and accessory sinuses 
The udder and supramammary lymphatic nodules 
The bone marrow 
The microscopical report 

Inspection of Special Organs. — The essentials for diagnosis 
which are to be looked for and recorded are about as follows : 1 . Name 
of the organ; from what animal; whether it died or was killed; 
whether the organ was entire or fragmented; whether parts, lobes, 
etc., have been amputated; and if there are any adhesions to adjacent 
parts. 2. Weight. 3. Length and breadth of the part. In the ab- 
sence of a tape measure we may ascertain these dimensions approxi- 
mately by comparison with the breadth of the hand and the length of 
the finger. Every person should know the length of his index-finger, 
which is usually about ten centimetres and may be used to measure 
organs, pathological spots, streaks, canals, etc. 4. Surfaces : whether 
smooth, even, wavy, granular, corrugated, rough, transparent, or 
cloudy. Color of the surface: general and primary color, special 
deviations and shades. The external contour of the organ and any 
prominences, with especial reference to their size as compared with 
grains of sand, millet-seeds, lentils, peas, beans, hazel-nuts (or filberts), 
a pigeon's, a hen's, or a goose's egg, the fist, the thickness of a child's 
arm, a child's head, a man's head, etc. 5. The consistence as deter- 
mined by palpation: soft, elastic (like the lungs), doughy, splenified, 
hepatized, tough, inelastic, carnified, indurated, leathery, like the kid- 



3°4 



POST-MORTEM EXAMINATIONS 



neys and skin, as hard as wood, cartilage, bone, or stone. 6. Section- 
ing of special parts : through the compact, so-called parenchymatous 
organs (muscles, liver, kidneys, lungs) large dissecting incisions are 
made. Through the brain and heart sections must be made in a certain 
way in order properly to expose certain cavities. On sectioning notice 
the resistance of the tissue, whether it cuts easily or is tough and pulls, 
whether the knife creaks as it goes through, whether the tissue is so 
hard that a saw is necessary, and observe if any fluid follows the sec- 
tion or if there are any abnormal contents. The surfaces of the section 
must be noted, their color, thickness, consistence, fluidity, and vascu- 
larity, as well as any other peculiarities which may be present. The 
pathological diagnosis is made by considering the details gained in this 
way, which lead to one conclusion and exclude another. A gross ana- 
tomical diagnosis is often only provisional and dependent upon micro- 
scopical and chemical confirmation. 



CHAPTER XXVII 

MEDICOLEGAL SUGGESTIONS 

Although a physician is not expected to have a profound knowl- 
edge of legal matters pertaining to his profession, yet every doctor 
should be more or less familiar with the medical laws of the State or 
county in which he is practising. He should be well acquainted with 
the regulations of the board of health, of the coroner's office, 1 of the 
criminal court, etc., and do all in his power to aid in their rigid 
enforcement. A synopsis of such laws and regulations is usually 
readily obtainable in book form, and nearly every physician has among 
his patients or friends a lawyer who is glad to discuss legal questions 
in return for medical information. Some of the salient points relating 
to medicolegal investigations and autopsies will here be briefly con- 
sidered, though many references to these matters will be found else- 
where throughout this work, especially in Chapter XXVIII. 

Obligations of Physicians to their Patients. — The obliga- 
tion of a physician to society in the practice of medicine is in a certain 
sense voluntary. His is the right to refuse any and all cases that may 
apply to him for treatment or advice. Services once begun, however, 
he must, after giving notice of his intention to discontinue them, allow 
his patient reasonable time to fill his place, as otherwise he renders 
himself liable for damages. This obligation is equally binding in 
the case of charity patients. Contracts between a physician and a 
patient may be either implied or express. In the former neither party 
specially promises anything. An express contract may specify any- 
thing not contrary to public policy. Contracts making the payment 
contingent upon successful treatment are valid, but, should the patient 
fail to follow the doctor's directions or to give him sufficient oppor- 
tunity for treatment, the Court would probably allow the latter reason- 
able compensation. If the physician fail to exercise ordinary skill, 

1 The office of coroner is an old and important one. It was established 
during the reign of King Athelstan, 925 A.D., and more clearly denned after the 
Norman conquest. The institution was brought to America by the colonists. The 
authority of the coroner to hold an inquest is not confined to the body of a person 
who may have died within his jurisdiction, but extends to all bodies brought 
within his territory, no matter where death may have taken place. (Witthaus.) 

20 305 



306 



POST-MORTEM EXAMINATIONS 



he renders himself liable for malpractice. In law malpractice consists 
in wilful or negligent acts or acts which are expressly forbidden by 
statute and by which a person suffers injury or death. It is a criminal 
offence to practise medicine or surgery while intoxicated. 

Expert Testimony. — Applying these principles pertaining to 
medical practice to our subject, no Court can compel a physician to 
give expert testimony, to make autopsies, or to conduct laboratory 
investigations without his consent, but any knowledge which the 
doctor may possess pertaining to an individual criminal case must be 
given to the Court in the same manner as if he were an ordinary 
witness. His scientific training is, however, his own personal property, 
the result of many years' study, careful research, and expenditure of 
money, and he is entitled to commensurate remuneration for the expert 
use of his knowledge. For the good of society, any facts pertaining 
to a given criminal case which are known to him should be freely and 
willingly given to the Court, though he thereby may be put to consider- 
able loss of time and money. 

Whether the Court may compel him to divulge professional secrets 
is a debatable question. In some states and countries such confidences 
of the patient are held sacred, as are the confessions to a priest ; while 
in other places such confidences (wrongly, we believe, in civil cases, 
but rightly in first-degree criminal cases) must be divulged to the 
Court should questions be asked the physician pertaining to the same 
while on the witness stand. 

An expert is one who, by reason of his peculiar experience, special 
study, or performance of certain duties, is in a position to form an 
opinion or judgment such as could not be expected from the judge 
or jury. No regular witness is permitted to express a mere opinion, 
as this is supposed to be the province of the members of the jury. 
Thus, in one of my cases, where infanticide was suspected, an iceman 
had found the dead body of the baby in an ash-barrel, and the judge 
would not permit the iceman to act as an expert in giving the approxi- 
mate weight of the child, though it would seem that, on account of his 
frequent weighing of ice, he would be more fitted to give a correct 
estimate of the weight than an ordinary person. The weight of the 
child (nine pounds) was desired in order to show that it was born at 
or near full term. 

A medical man should refuse to testify as an expert unless he is 
thoroughly qualified. In no case should he go on the witness stand 






MEDICOLEGAL SUGGESTIONS 307 

without being as fully informed as is possible on the subjects on which 
he is to be examined, nor should he allow himself to be questioned on 
subjects on which he is not prepared. He should be honest and candid 
with those securing his services before the trial, and, no matter what 
may by the consequences, his answers while on the witness stand must 
be made with absolute impartiality. 

The medical expert should at all times confine himeslf to purely 
medical topics and never become involved with matters that will place 
him in the light of an ordinary witness, of a detective, or of an 
attorney, and he should carefully avoid acting as a champion of the 
parties who are paying for his services or attempting to plead one side 
of the case. 

His language should be as free as possible from technicalities and 
such as can readily be followed by the least educated of the twelve 
jurymen, many of whom are, unfortunately, unfit for the performance 
of their duties. Some judges carry this plainness of language to an 
extreme. Thus, while acting as an expert in a murder trial, the writer 
was once requested by the judge not to use the word " hemorrhage" 
in testifying, as this term was too technical for the jury to understand. 
I at once substituted " bleeding" for the objectionable word and pro- 
ceeded with my testimony. When not positively certain of a point he 
should unhesitatingly acknowledge the fact; thus harm and the pos- 
sible endangering of a human life will be avoided. But when sure 
of his ground he should undeviatingly adhere to it. At the close of 
his testimony, especially if long and exacting, an opportunity is almost 
always given him to correct any misstatements which he may inadver- 
tently have made, and to make clear the meaning of any dubious points 
of his original testimony which may have been clouded by the cross- 
examination of the opposing counsel. 

Too much is often expected from the expert, as the following 
instance shows. While testifying as an expert in a country town on 
a case where the postmortem revealed beneath the left eye a small 
incision closed with two stitches, ecchymosis about the eyeball, and a 
fracture of the skull, the district attorney and the judge criticized me 
severely because I would only state that the man had died from 
hemorrhage of the brain due to fracture of the skull. They desired 
me to say that the man had been knocked down with the fist of a 
person who had a ring upon his ring-finger, and that in this manner 
the fracture had been produced. I was naturally willing to say that it 



308 POST-MORTEM EXAMINATIONS 

could have been produced in this manner, but would not say, much 
to their apparent disappointment, that it was so caused. 

Identification of the Body. — Before a postmortem is begun, 
the remains should, if practicable, be positively identified to the obdu- 
cent by one or more persons who knew the individual during life. 
If this is impossible, the one finding the dead body or those having 
seen it in its original situation after death and those removing the 
cadaver from one place to another may act as identifiers. Persons who 
have gone under several names should be recorded under their legally 
correct name, any other aliases which had been used being also 
recorded. 

That the place where an unidentified body is found should be care- 
fully stated is shown by one of my cases. A colored woman con- 
fessed the placing of the corpse of a new-born male bastard wrapped 
in a shawl in an ash-barrel on the corner of A Street, Philadel- 
phia, Pennsylvania, in which State the concealment of the death of an 
illegitimate child is a penal offence. The body identified at the post- 
mortem was that of a new-born colored babe wrapped in a shawl, but 

found in an ash-barrel situated at the corner of B Street, some 

two blocks away. On the plea of the lawyer for the defence that there 

was no corpus delicti, as the body found at B Street was not 

shown definitely to be the body left at A Street, the judge decided 

that the trial should not proceed and ordered the jury to acquit. This 
was at once done, and, though new evidence might later be secured, 
it could not be used, as the woman could not have her life put in 
jeopardy a second time, though, as in the Mollineux trial, a man 
might once be condemned but on a new trial be acquitted. 

Should personal identification be impossible, a cast of the face, a 
photograph, an accurate description of the body, with a full and clear 
statement of any peculiarities, should be made. Clothing alone is not 
sufficient for purposes of identification, as bodies have been substituted 
and clothed in the wearing apparel of the alleged deceased, such substi- 
tutions being made in order to defraud life insurance companies or 
change succession to titles and estates. 

As the person whose body is being examined may have been a crim- 
inal and thus during life have had the Bertillon system applied for pur- 
poses of future identification, these measurements and finger-impres- 
sions should be secured in important cases. Skiagraphs of old osseous 
lesions might also lead to identification. 



MEDICOLEGAL SUGGESTIONS 



309 



Care of Clothing and of Surroundings. — Where the clothing 
has not been already removed by responsible persons, as is done in 
certain places (though this is scarcely justifiable), the examiner should 
observe the condition of the articles and their position, whether torn 
or soiled, displaced or reversed. If any irregularity is observed, he 
must determine, if possible, any significance that may be attached 
thereto. For example, singeing about a small recent bullet hole, with 
the powder markings pointing upward, would indicate that the powder 
used was black and not smokeless, that the weapon was discharged at 
close range, and that the trigger was held in the opposite direction, — 
i.e. 3 down. 1 Again, recent seminal stains on or marked disarrange- 
ment or tearing of the clothing of a female would strongly suggest — 
at least an attempt to commit — rape. When he has satisfied himself 
by this examination, the obducent may remove the clothing, which, 
where necessary, should be disinfected and preserved from destruction 
by moths or other injuries agencies. Thus, in a suit of clothes pre- 
served to show the entrance and the exit of a bullet, it is disappointing 
at or just before the trial to find the material so badly moth-eaten as 
to be useless for demonstrative purposes. As one's memory is treacher- 
ous, spots to be remembered, such as those showing blood, should be 
marked with thread or ink and a careful note made as to their exact 
location. 

The desire of the police to be on friendly terms with the reporters 
often renders the study of the surroundings impossible or misleading. 
In one of my cases, a brutal murder by violence, the scene had been 
visited by dozens of persons and the body removed to an undertaker's 
before the writer was summoned to perform the autopsy. The im- 
portance of ascertaining the nature of the substance upon which the 
body rested is shown by my finding at the postmortem in the rectum 
of a four-year-old boy " needles" from a Christmas-tree, and the later 
securing of a similar " needle" in the hat of the murderer and sodo- 
mist many blocks from the place where the crime was committed. 

The Corpus Delicti. — In many cases where homicide has been 
committed and the murderer has attempted to destroy the evidence 
of his guilt, or in destructive accidents, the corpus delicti has been 
proved by the finding of a part or member of the body or a portion of 
the clothing, as a piece of charred bone, a tooth, a ring, or a button. 

1 Brinton, International Clinics, October, 1902. 



3io 



POST-MORTEM EXAMINATIONS 



On the other hand, instances are on record where deluded individuals 
made confessions of murder which were proved to have been un- 
founded by the subsequent appearance in life of the person said to 
have been killed. So important is this point that time and time again 
juries have failed to convict where the moral evidence was wellnigh 
conclusive. It is only upon irrefutable evidence that the fundamental 
principle concerning the corpus delicti is disregarded. 

Where only a part of the body is available for examination, con- 
siderable difficulty is apt to arise as to the best method of procedure. 
The examiner will then need to possess a wide knowledge of com- 
parative and pathological anatomy and to exercise great ingenuity in 
order satisfactorily to demonstrate the identity of the parts submitted. 
Should the only proof of the corpus delicti be a skeleton or a portion 
of one, the expert will be asked to determine the age, race, and sex 
of the person and the probable date at which death took place, — 
whether the bones are old or recent. Thus, in the case of Wakefield 
Gaines the trunk alone was found, the head and limbs having been 
severed from the body. With limitations, the age would be known by 
the condition of the epiphyses, whether or not united; by the cranial 
sutures, whether or not closed; and by the state of dentition. Race 
would be indicated by the different racial characteristics and peculiari- 
ties : thus, the negro by his splay-foot, projecting heel, and prog- 
nathous jaw; the Caucasian by his higher forehead, wider facial angle, 
and larger cranial capacity. Evidence of this character is not, however, 
absolutely conclusive. The determining of sex, after the age of 
puberty, presents less difficulty. In man the size of the cranium is 
greater and all the bony points are heavier and more prominent, the 
angle of the neck of the femur with the shaft is greater, and the lower 
jaw is heavier; in woman the ribs are lighter and more compressed, 
the patella is smaller, and the articular surface of the femur and tibia 
is narrower. The characteristic differences are, however, found in 
the broad female pelvis, the diameters of which are all greater with 
the exception of the vertical ; the sacrum and coccyx are more curved 
and there is greater spread of the arches of the pubes. 

The probable age of the bones would be indicated by their condition 
and appearance. The presence of the marrow and the periosteum is 
the most conclusive evidence of a recent state. The soft parts are 
usually destroyed within two years. Under ordinary conditions the 
body skeletonizes in about ten years, although this period is subject 



MEDICOLEGAL SUGGESTIONS 3H 

to wide variations, depending upon the cause of death, the chemical 
properties of the soil in which the body was found, and whether or 
not preservatives were used. 

Medicolegal Postmortems. — The objects of a medicolegal post- 
mortem include the finding out of the cause and mode of death, the 
establishment of a corpus delicti, the determination as to whether a 
crime has been committed, and if so the discovery of a motive therefor 
and the exact nature of the process employed therein. In such legal 
investigations the pathologist should protect his reputation in every 
possible manner, and he should hesitate to make a postmortem with- 
out the presence of a witness, who should, if possible, be a professional 
brother. Never forget that the findings of the autopsy should be 
dictated to an amanuensis during its progress, verified at its comple- 
tion, and the record signed. 

In general the medicolegal post-mortem examination does not 
differ materially from the pathological, except that in the former 
greater precautions are necessary in order to avoid sources of error or 
confusion, and that the cranial contents are examined before opening 
the large blood-vessels, as signs of congestion disappear after the 
severance of the aorta and venae cavae. The importance of examining 
the vertebrae in all autopsies was illustrated recently by an article in 
the Lancet. Two cases were reported of fracture of the cervical 
vertebrae without external signs of violence, and in each case there was 
present a lesion of the heart which would have been assigned as the 
cause of death had not the real cause been demonstrated in the inspec- 
tion of the vertebral column. In some cases after a most rigid and 
painstaking inspection no cause of death can be ascertained, but with 
care and systematic examination mistakes and inaccuracies will be 
reduced to a minimum. 

In case of suspected poisoning the primae viae should be tied at 
each end and removed. Double ligatures should then be applied at the 
junction of the duodenum and the ileum and at the end of the small 
intestine, dividing the viscera into three portions. The contents of the 
stomach and those of the intestines should be emptied into separate 
jars. Many poisons are extremely volatile and without great care 
traces of them may be lost and justice defeated. 

Each organ should be received in a separate receptacle, and each 
receptacle should be marked, sealed, dated, and deposited where tam- 
pering with it would be impossible. 



312 



POST-MORTEM EXAMINATIONS 



The form of report used by the writer in medicolegal cases is as 
follows : " I made a post-mortem examination of the body of Walter 
Foster on April 10, 1898, at St. Agnes Hospital, Philadelphia. The 
body was identified by George Bell, 636 Siegel Street, and Michael A. 
Bruder, 1847 Sartain Street, both of Philadelphia. I find that death 
was caused by shock and hemorrhage from stab- wound of the heart." 

While acting as coroner's physician I rarely volunteered more than 
this, but waited for the district attorney to ask questions in regard to 
the nature of the wound and as to other facts of interest. By this 
method the jury is not confused by an enormous amount of irrelevant 
testimony, though the expert must be prepared to give, under cross- 
examination by counsel for the defence, the minutest details as to how 
the postmortem was performed. 

Autopsies on Infants. — The first question to determine in the 
examination of a babe ts, was it born alive? If so, was it a full-term 
child or a premature birth ? If born dead, how many months of uterine 
gestation caused it to reach its present development, and after attain- 
ing its maximum growth was it carried as a foreign body in the uterus ? 

Determination of the Viability of a Child from the Post- 
mortem Appearances. — The reader is advised carefully to read 
Paragraphs 23 and 24 of Virchow's regulations for the perform- 
ance of medicolegal postmortems. To discover the ductus arteriosus 
remove the thymus gland, incise the right ventricle along its septum, 
and extend the incision into the pulmonary artery along the middle 
portion of its anterior wall. The orifice is situated between and 
beyond the two openings of the right and left pulmonary branches. 
If the duct is open, a sound will readily pass into the aorta. 

If in the hydrostatic test the lungs float on top of the water, they 
have been completely aerated,- a strong proof of breathing at or after 
birth; if they float beneath the surface, aeration is incomplete; and 
if they sink, no respiration has occurred. Decomposition of the lung 
tissue may cause it to float. A very valuable sign of the viability 
of the child is the presence of uric acid crystals in the kidneys. 

Ante-natal rigor mortis may be met with, and does not prove, as has 
sometimes been asserted, that the infant was born alive in the legal 
acceptation of this phrase. Rigidity of the fcetus may unduly prolong 
labor by interfering with delivery. 1 

1 Lancet, February 14, 1903, p. 460. 



MEDICOLEGAL SUGGESTIONS ^3 

The Lancet of April 26, 1902, raises the query whether the dead 
body does not possess properties akin to radio-activity,, and alludes to 
the photographs taken by Vignon and exhibited by him, with the wind- 
ing sheet preserved at Turin and traditionally said to be that of Christ, 
which seem to justify the belief that the human body is either radio- 
active or that it gives off vapors which exhibit a similar action to light 
upon sensitive surfaces. Peroxide of hydrogen may be the main factor 
concerned. 

Period of Intra-uterine Gestation. — In deciding the age or 
period of development of the infant the external evidences of value 
are : ( 1 ) Length and weight of the child ( for tables of dimensions 
and weights of the new-born see page 268). (2) Conditions of the 
skin and its appendages. In the healthy babe at full term the skin 
is white and covers the body smoothly; woolly hairs are present in 
perceptible numbers only on the shoulders; the hair of the head is 
from two to three centimetres long; the nails are hard and horny, 
extending beyond the ends of the fingers, but not of the toes. (3) 
Condition of the umbilical cord, which at term is fifty centimetres 
in length and is inserted somewhat below the middle of the abdomen, 
falling off by inflammatory demarcation on the fifth or sixth day. 
(4) State of the cartilages of the nose and ear, being hard in the 
mature infant. (5) Presence or absence of the membrana pupillaris, 
which disappears after the eighth month. (6) Condition of the 
genitals in both sexes; as descensus begins at the seventh month, the 
testicles of the full-term male should be in the scrotum ; in the female 
the labia are generally found closed. (7) The measurement of the 
fontanels, of the cranium, and of the transverse diameter of the body 
at the shoulders and hips. (8) The size of the centre of ossification 
(Beclard's) in the lower epiphysis of the femur. To reach this the 
leg is flexed on the thigh, a transverse incision is made below the 
patella, which is removed, and the femur is then exposed. Thin, 
transverse sections of the cartilage are made until the greatest diameter 
of the centre of ossification, if present, is reached. The centre is 
absent before the thirty-seventh week, and in the child at full term 
has a diameter of from two to three lines, though it may even then be 
absent. If the diameter is more than three lines, the child has very 
likely lived for a certain length of time. ( Reese. ) The osteochondral 
line is also to be examined for syphilitic changes. 

From the internal examination important evidence as to the age 



3H 



POST-MORTEM EXAMINATIONS 



of the child and especially as to respiration is secured. Upon ex- 
posing the abdominal cavity, which is to t>e done before opening the 
thorax or cranium, the position of the diaphragm in its relation to 
the ribs is immediately noted, as especially urged by Virchow. If 
the lungs do not contain air or are but partially distended, the 
diaphragm reaches to the fourth rib; when the lungs are fully dis- 
tended, the diaphragm is at the fifth or sixth rib on the right, and at 
the sixth rib or intercostal space on the left. 

To facilitate the examination of the umbilical vessels, Nauwerck 
recommends a division of the usual abdominal incision, shortly before 
reaching the navel, into two diverging incisions extending to the 
pubes. The abdomen is opened, and the umbilical vein, made promi- 
nent by traction on the triangular flap, is traced along its course, 
opened with small scissors, ligated, and divided. Turning down the 
flap over the pubes exposes for examination the umbilical arteries to 
either side of the remains of the urachus. (Fig. 140.) 

Criminal Abortion. — Formerly abortion was not legally a 
crime if performed with the consent of the mother prior to the 
viability of the foetus. It was at one time not regarded as murder 
even to take the life of a child at any period of uterine gestation. 
The barbarousness and danger to society of this view were early 
recognized, both abroad and in this country, and various laws with 
different penalties attached thereto were enacted making it a crimi- 
nal offence to practise abortion at any period of gestation, unless for 
the express purpose of saving life. (Witthaus and Becker.) 

There is no other class of cases so trying to the patience, ingenuity, 
and skill of the pathologist as those of abortion, which is accom- 
plished by numerous methods. Many respectable women expose 
themselves to cold, falls, and douches with the hope of relieving 
themselves of their offspring apparently by accident. Many pills 
and potions are sold to induce a resumption of the menstrual dis- 
charge, and one often finds them on sale in drug-stores of the first 
rank. These nostrums are sometimes composed of poisons that may 
cause the death of the mother. The use of instruments, especially 
the spiral douche advertised in so many papers, is a very common 
method of procedure. Indeed, the most successful criminal abor- 
tionists operate so that, unless through accident, no evidence of the 
operation is left. Usually all that can be found is evidence of a recent 
pregnancy. 



MEDICOLEGAL SUGGESTIONS 



315 



When violence is clone to the child, the nature of the injuries 
must be carefully noted. When violence is done to the uterus, some 
form of infection usually follows. Care must be taken in examina- 
tion to exclude the possibility of previous disease of the uterus or 
adnexa as a cause of the infection or possibly as a cause of abortion. 
In former days, when curettage was more used than it is now in 
the treatment of abortion, an additional factor was added, making it 
difficult and often impossible to distinguish dilatations of the os due to 
the instrument producing the abortion and to the passage of the foetus 
from those induced by the introduction of the curette and the subsequent 
packing with iodoform gauze. Care should be taken to compare the 
vital history of the foetus with the physical condition of the mother, 
the history of sexual life of the parents, specific disease, etc. 

Signs of Death. — Space permits only brief mention of the 
signs of death; the reader interested in this subject is referred to 
Brouardel's work on death and sudden death. 

The positive signs of death in an unmutilated body are decom- 
position, complete loss of temperature, and cadaveric lividity and 
rigidity. The negative signs are : ( 1 ) Cessation of respiration, 
determined by holding before the nostrils a down feather, a small 
flame, or a cooled mirror, or by placing a glass containing water on 
the epigastrium. (2) Cessation of circulation, ascertained by obser- 
vation, palpation, section of a small artery, transmitted light through 
web of fingers, loss of vasomoter constrictors, acupuncture of the 
apex of the heart, emptiness of the arteries, etc. (3) Cessation of 
nervous and muscular irritability, determined by application of light 
to eye, or of cold, heat, force, electricity, irritants, etc., to skin. (-4) 
Cessation of tissue vitality, abolition of reflexes, etc. 

Respirations usually cease by a moment before the heart-beats stop, 
but sooner in the new-born than in others. In the last agony or shortly 
after death the pupils dilate, but within an hour contraction sets in, 
which lasts from three to four days, the contractions of the pupils often 
being unequal. Spermatozoic movements may be found in those dying 
suddenly more than twenty-four hours after death in suitable cases. 
Lowering of temperature occurs first on the surface, requiring, accord- 
ing to good authority, twenty-three hours to become complete. 

Premature Burials. — That premature interment has occurred 
is undoubted. In Munich the popular belief in such instances is so 
great that the body is placed in a specially prepared room, with a 



3 i6 POST-MORTEM EXAMINATIONS 

bell in the hand of the corpse ready for use in case of an emergency ! 
Such notions usually originate from careless handling of the coffin, 
from the expulsion of a foetus by the formation of gases in the body of 
a pregnant woman, from real or apparent growth of hair, from conver- 
sion of bodies into adipocere, etc. 

Usual Causes of Death. — In Chapter XXIX. will be found a 
list of all the recognized causes of death, and it is recommended that 
this classification be used by every one in order that uniformity of 
nomenclature may be secured throughout the world. Sudden death 
is usually due to failure of the circulatory apparatus, to cessation of 
respiration, to disturbance of the nervous system, to deficient nutri- 
tion, to poisons either produced within the body or introduced from 
without, or to violence by physical or chemical forces, heat or cold, 
electricity, wounds, missiles, etc. 

Many conditions that have existed a long time may cause sudden 
death by breaking the balance of life. Thus, in chronic nephritis 
uraemia may develop suddenly and cause death after only a very slight 
illness. Again, an aneurism may rupture without sudden increase in 
the symptoms or any violence, simply by a natural slow progress of 
the lesion. All mortal diseases and many that by themselves do not 
end fatally may contribute to the causing of sudden death as well as 
to the slower dissolution. 

No disease causing severe disturbance of heart, kidney, lung, 
nerve, or digestion can be ignored in estimating the factors that 
brought about the death of the patient. Certain maladies of common 
occurrence should be in our minds in making examinations, though 
never so prominently as to prevent a proper search for other con- 
ditions. Thus, in children think of pneumonia, enteritis, bronchitis, 
meningitis, congenital syphilis and other hereditary diseases, infec- 
tious fevers, malformations, etc. ; in young adults, infections, local 
and general, violence, typhoid fever, and tuberculosis; in middle 
life, diseases of the lungs, kidneys, heart, and blood-vessels, hepatic 
and gastro-intestinal conditions, infections, violence, occupation 
neuroses, pneumonia, tuberculosis, cancer, etc. ; in old age, nephritis, 
carcinoma, sarcoma, aneurism, cerebral hemorrhage, embolus, throm- 
bosis, tumor or abscess, arteriosclerosis and obstruction of the coro- 
nary arteries, heart lesions, etc. 

In coroner's cases death very commonly results from heart ex- 
haustion, due, as the case may be, to intrinsic disease, to excitement, 



MEDICOLEGAL SUGGESTIONS ^jy 

or to poisons. Care should be taken to determine the cause of this 
exhaustion, whether it was due wholly to heart disease, such ' as a 
valvular lesion, or to one of the exciting causes. In kidney con- 
gestions consider whether death was due to failing heart causing 
passive congestion, to poisons, or to inflammatory congestion, such 
as would be part of an acute nephritis. Ascertain if the oedema of 
the lungs is dependent upon cardiac, renal, or cephalic lesions or 
primarily upon a lung condition principally. 

Decomposition. — The bodies of infants decompose more quickly 
than those of adults. The process begins earlier in plethoric and 
fat adult bodies than in thin aged persons. It is more rapid after 
muscular activity and in those dead of acute diseases, fevers, heat- 
stroke, sepsis, suffocation by gases, etc., while it is longer delayed in 
cases where the system is exhausted and muscular irritability retarded, 
and in the bodies of those fatally poisoned by hydrocyanic acid, 
carbonic acid, sulphuric acid, etc. Arsenic may or may not prevent 
decomposition. At the same temperature a body which has been 
for one week in the air, one which has been two weeks in water, and 
one which has been eight weeks buried will show similar degrees 
of decomposition. (Brown-Sequard.) 

Hofmann recommends in cases where decomposition is much ad- 
vanced the removal of the brain in the ordinary manner, the making of 
some openings in the skin, the washing of the entire body in running 
water for twelve hours, and the further bathing of the corpse in a con- 
centrated alcoholic sublimate solution or chlorid of zinc for an equal 
period. The green coloration due to decomposition disappears to a 
marked degree under this treatment. 

The length of time which has elapsed since death has to be deter- 
mined by the circumstances peculiar to each case. So many considera- 
tions may apply that in many instances it is dangerous to be too 
dogmatic. 

Violent Death. — When there is doubt as to homicide, all the 
precautions necessary for such cases must be strictly observed. The 
sort of violence, its mode of application, and something of an estimate 
as to the amount, direction, and conditions of application of force can 
usually be made from post-mortem examination. In the inspection 
of wounds the condition of the tissues and the position and direc- 
tion of all lesions discovered are to be very carefully noted, as some- 
times the instrument with which they were inflicted may safely be 



318 POST-MORTEM EXAMINATIONS 

inferred therefrom, and at times the findings will point to the cir- 
cumstances under which the injuries were received. A minute descrip- 
tion of the injuries is absolutely necessary, so that if called upon in 
court an exact account of them can be given. The amount of con- 
tusion, laceration, extravasation of fluids, and damage to any vessels 
must be carefully noted. In gunshot wounds the projectile should be 
found : this is imperative. About the wound of entrance look for 
powder marks, singeing, and smudge. If the projectile struck a bone, 
a splinter may have been detached and caused injuries not along the 
line of the main wound. Death is frequently due to shock, which 
may result from a blow that leaves no mark visible at the post- 
mortem. This is quite uncommon. Injuries to the head make it 
necessary to estimate the structural and tensile strength of the skull 
in each case. When a fracture of the skull is found or suspected, the 
skullcap must be cut away with the saw only, not using the chisel. 
Contrecoup must always be considered in hunting for fractures and 
lacerations of blood-vessels. 

Burns and Scalds. — Burns are produced by dry heat and show 
when fresh no maceration of the tissues. When inflicted by intense 
heat or by flame, there will be found scorching or singeing of clothing 
and. hair, and possibly of flesh. When resulting from contact with a 
hot surface, note especially the shape of the burn, and, if the supposed 
hot object is to be obtained, a corresponding mark may be found 
upon it. In burning the hair often reddens. 

Scalds are produced by vapor, steam, or a liquid, and usually 
show some trace of the action of the fluid on the mucous membrane 
or skin. In plain scalds singeing is absent, but where fire has fol- 
lowed an explosion both scalds and burns may be found. In such 
cases the mucous membrane of the air-passages should always be 
examined. 

In cases of scalds and burns the extent of the injuries must be 
determined both in breadth and in depth, with a careful observation 
of secondary changes, such as sepsis, internal congestions, and inflam- 
mations. There is probably produced by these means a product 
poisonous to the organism, which acts as in other forms of auto- 
intoxication. 

Death by Electricity. — There are no absolute and constant 
indications. In some cases the point of entrance or of exit can easily 
be made out by the change in tissues or in clothes. Frequently there 



MEDICOLEGAL SUGGESTIONS 3^ 

is marked burning of the skin. In many instances the only evidence 
is an unnatural rigidity of the muscles, sometimes with distortion, due 
to a coagulation of the muscle substance by the current, which, if found 
in one part and not in another of the same body, may be of signifi- 
cance. There may be evidence of electrolytic action in the blood and 
organs, as in the brain and cord. There may be livid areas, even hemor- 
rhages, though after sudden death they are not usual. 

The face is sometimes distorted. The heart is usually flaccid, 
although the left side may be hard or tense. On the right side dark 
fluid blood is often found distending both auricle and ventricle. The 
same condition exists in the left auricle, but the ventricle is almost 
empty. The pupils are invariably widely dilated immediately after 
death. The blood is usually fluid, but clots have been found in the 
heart and large veins. 

Jellinek 1 finds that the anatomical changes in the tissues resulting 
from the passage of a powerful electric current diminish the resistance 
of future currents. Mice are killed with a weak current, but pigs show 
the greatest resistance. Death by electricity occurs more quickly after 
administration of morphine or cocaine, but is retarded by chloroform 
anaesthesia. A dose of morphine might therefore be administered with 
benefit before an electrocution. Microscopically, degenerations are 
found in the gray matter of the spinal cord along with dilatation of the 
central canal and hemorrhages. 

Death from Heat or Cold. — After fatal heat-stroke the body 
is often very hot for hours and decomposition may be uncommonly 
rapid. There may be general internal congestion. It is usually 
necessary to know somewhat of the history of the case before a 
verdict can be rendered of heat-exhaustion, sunstroke, or thermic 
fever. In cases of death from cold we often find pallor or dislocation 
of the skin and a congestion of the viscera with blood of rather bright 
color. No single characteristic lesion results from exposure to 
moderate excess of either heat or cold. When no pathological lesions 
can be found, death is probably due to shock. Any chronic disease 
of viscera tends to reduce the power to resist severe temperature 
changes. There is no significance in the freezing of the body beyond 
showing that considerable time may have elapsed since death. The 

1 Wiener klin. Wchnschr., Nos. 16 and 17, 1902. 



320 



POST-MORTEM EXAMINATIONS 



frozen flesh of the mastodon sometimes found in the Siberian plains 
is good eating, though it must be thousands of years old. 

There are no characteristic changes in sunstroke. Rigor mortis 
comes on early. Lividity and putrefactive changes develop rapidly after 
and even before death. Venous engorgement is extreme, particularly 
in the cerebrum. The left ventricle of the heart is contracted ; the right 
is dilated and may be full of blood imperfectly coagulated and deficient 
in oxygen. The blood is fluid, dark in color, acid in reaction, and prob- 
ably contains, as in burns, a poisonous substance which acts on the more 
highly specialized cells of the body. Petechial patches may appear in 
the subcutaneous and subserous tissues. The elevation of temperature 
is often remarkable, and it is extremely disagreeable to make an autopsy 
in these cases, as I have done, soon after death, with a temperature of 
106 F. In a case of mine of stramonium poisoning, with a tempera- 
ture of nearly no° F., the clinician had diagnosed sunstroke. 

Infanticide. — Many methods have been resorted to, as exposure 
to cold, smothering in various ways, strangulation either by the hands 
or by a ligature around the neck, and wounding with various instru- 
ments, sometimes accompanied by efforts to conceal the act. The 
child may be intentionally drowned in a vessel containing fluids 
discharged from the vagina at the time of birth. Gross violence or 
poisons may be employed. 

Death by Starvation. — There is usually extreme emaciation, 
which is shown especially by a sinking of the eyes and an unfilled 
condition of the skin. It is sometimes necessary to determine whether 
starvation resulted from disease or neglect, especially in cases of those 
children which have been reared in foundling homes and hospitals. 

Suffocation; Strangulation; Hanging; Drowning. — All 
these produce death by asphyxia, or carbon-dioxid poisoning, com- 
bined with oxygen starvation, the signs of which are more or less 
marked. In death from asphyxia there are usually hemorrhages 
into the thymus gland, as well as Tardieu ecchymoses in the pleura 
and pericardium. 

Plain suffocation may show no marks of violence. The dark 
fluid blood, possibly hemorrhages from increased blood pressure, gen- 
eral congestion of the lungs, frequently congestion of viscera, often blue 
nails and lips, occasionally suffusion of the face with dark venous 
blood, and an absence of other pathologic conditions, give a general 



MEDICOLEGAL SUGGESTIONS 321 

type of finding that is not easily mistaken when clearly marked but 
is difficult to recognize when not conspicuous. 

Strangulation adds the factor of mechanical arrest of respiration, 
and may result from the presence of food, some foreign substance, 
or a growth or swelling in the throat. When due to throttling the 
marks about the neck are of great importance. There may be com- 
pression of veins. 

Hanging may cause death by injury to the spinal cord as well as 
by compression of the blood-vessels and air-passages. The parch- 
ment-like appearance of the skin on the sides of the neck and the 
rupture of the intima of the carotids afford valuable evidence. 

Wachholz 1 has shown experimentally that in acute suffocation there 
may be found, along with the soft currant-jelly clots in the heart, solid 
white clots embedded in the meshes of the cardiac muscle. La Cas- 
sagne and Martin have described a method, called docimasie hepatique, 
of diagnosing sudden death by a marked increase in the sugar contents 
of the liver of persons who ha\ r e died suddenly. Wachholz finds from 
his experiments that no such relation exists. 

Reuter, working with Kolisko, 2 from a study of twenty-two cases 
of throttling and two hundred cases of hanging, thinks that these two 
very similar modes of death may be differentiated from each other. In 
throttling there is ( 1 ) cyanosis of the face, with ecchymoses of the 
eyelids and conjunctiva. (2) The scalp, the coverings of the brain, and 
its membranes are always rich in blood. (3) As a rule, hemorrhages 
in the soft tissues of the neck, especially in the muscles, occur. (4) 
There is marked injection of the upper air-passages, combined with 
numerous small hemorrhages. ( 5 ) Injuries to the larynx and hyoid are 
rare. (6) Rupture of the intima of the carotid is never noted; in only 
three cases were there suffusions into the adventitia. In hanging ( 1 ) 
cyanosis of the face is usually not noted ; ecchymoses are seen in twenty 
per cent, of typical and in thirty per cent, of atypical strangulations. 
(2) The amount of blood contained in the organs in the skull varies, 
but usually consists only of that which was present in these parts at the 
time the circulation was interrupted. (3) Hemorrhages in the muscles 
are rare, — two per cent., in typical and fourteen per cent, in atypical 
cases. (4) Injuries to the laryngeal and hyoid structures are com- 



1 Vrtljschr. f. gerichtl. Med., 1902, p. 34. 

2 Zcitschr. f. Hcilk., 1902, vol. xxii. 

21 



322 POST-MORTEM EXAMINATIONS 

mon, — sixty per cent, in typical and thirty per cent, in atypical cases. 
(5) Rupture of the intima of the carotids occurs in five per cent, of 
typical and four per cent, of atypical hangings. The external markings 
on the neck are also often different. 

In a case of drowning water or foreign substances may be found 
in the openings of the body, in the respiratory organs, or in the 
stomach, or death may be due to spasmodic arrest of respiration. The 
froth from the air-passages is coarser than that seen in cases of 
oedema. Very soon after death we often find watery fluid in the pleura. 
The spongy condition of the lungs is found only where there has 
been inhalation of water, which does- not always happen. After 
decomposition has set in, the evidence of drowning gradually dis- 
appears until it is impossible to make the diagnosis. 

Blood-Stains. — When any suspicion of violence occurs, look 
carefully for blood-stains. If possible, determine whether any stains 
found are blood. If in doubt, treat them as if they were, unless some 
special reason exists for not doing so. Such stains should be most 
critically examined in the privacy of the laboratory. Try to ascer- 
tain : (1) Their connection with the person examined. (2) Their 
source. (3) Their extent, using great care in determining the nature 
of the substance stained and whether there has been flowing or run- 
ning, to be judged partly by shape and direction of the stains. (4) 
Conditions, — whether fluid or clotted, wet or dry, cracked or caked, 
etc. (5) How made, — whether by smear, by splash, by flow, by 
soaking up as in cloths, etc. (6) Connect, if possible, the amount, 
shape, and condition of the stains with their probable source and 
note any peculiarities. When practicable, preserve parts or all of 
stains. It is often well to saw off an entire step or remove a panel, 
in order to produce the same as evidence in court. In the present 
state of our knowledge it is not safe to state from what part of the 
body the blood came and the age of the stain, though the more recent, 
the more soluble. 

Two illustrations from my case-book will show the importance of 
this line of research. A man committed rape on a child, and blood 
was seen on the fly of his trousers by his room-mate. In order to 
divert suspicion from himself, he accused his room-mate of the crime. 
The trousers of both men were sent to me for examination. In the 
pair of pants belonging to the perpetrator of the crime the lining of 
the fly had been cut away and neatly sewed, but there remained a 



MEDICOLEGAL SUGGESTIONS 323 

few telltale threads containing blood, which was found to possess the 
characteristics of human blood. On the trousers of the other man 
was found a red substance, which examination showed to be lumber- 
man's red chalk, the crime having been perpetrated in the backwoods. 
In the second case blood splashes on a white curtain were stated by 
a murderer to be red paint which one of his children had put there 
with a paint-brush. • 

The presence or absence of blood is determined by the ( 1 ) physi- 
cal examination; (2) chemical tests; (3) spectroscopical examina- 
tion; (4) microscopical examination; and (5) the hemolytic serum 
test. One of the most recent and valuable books on this and kindred 
medicolegal subjects is that of Glaister. 1 

I am unaware as yet of any murder trial in which the new aggluti- 
native reaction for the diagnosis of human blood has been applied. It 
will certainly be a feature of all such trials in the future, as when used 
in conjunction with the other tests it would seem to afford positive 
proof of the presence of human blood. Uhlenhuth 2 was put to a severe 
test by the German Department of Justice. Various objects stained 
with the blood of man and of different animals were sent to him, the 
nature of the blood being known to the Department of Justice, but not 
to him. When the blood was furnished in sufficient quantities, his 
results in each case were positive. One method of applying the test is 
as follows : 

Ten cubic centimetres of defibrinated human blood are injected into 
the peritoneal cavity of a rabbit at intervals of six days, and after five 
such injections an effective serum should be obtained. The blood to be 
tested is then diluted with water, one to one hundred, and filtered. Of 
this clear, slightly red solution, two cubic centimetres are placed in a 
small tube and mixed with an equal quantity of 1.6 per cent, salt solu- 
tion; six to eight drops of the serum of the rabbit are then added to 
each tube about to be tested, but all will remain perfectly clear except 
the tube containing human blood. The reaction is extremely delicate 
and can be obtained with very slight traces of even old dried blood. 
Deutsch, 3 Wassermann and Schultze, 4 and Dieudonne 5 describe prac- 

1 A Text-book of Medical Jurisprudence, Toxicology and Public Health, 1902. 
2 Deutsche med. Wchnschr., September 11 and 18, 1902. 
a Orvosik Lapja, 1901, No. 11. 

4 Berl. klin. Wchnschr., 1901, vol. xxxviii., No. 7. 

5 Munchen. med. Wchnschr., 1901, No. 14. 



324 POST-MORTEM EXAMINATIONS 

tically the same method as Uhlenhuth and have obtained the same 
results. The first of these claims to have been the first to use this 
method of differentiating human blood, while the last found that the 
same result could be obtained with human urine and human pleural 
exudate, although to a less degree. 

Corin * believes that the active principle of the serum in the bio- 
logical differential diagnosis of the blood is paraglobulin, for not only 
may blood-serum be used for this purpose, but also transudates con- 
taining globulin. The paraglobulin in an ascitic fluid was precipitated 
by magnesium sulphate, dried, and injected into animals in an aqueous 
solution. In like manner the paraglobulin can be precipitated from the 
blood of the animal experimented upon and preserved in pulverized 
form. This powder when wanted for use is dissolved in water and 
employed in testing the blood under examination. Biondi 2 finds that 
the reaction occurs with the semen, so that human and animal sper- 
matic fluid can be differentiated. The reaction was also secured from 
many of the normal and abnormal secretions and excretions of the 
body. 

Butza 3 prepares the animal by injecting from ten to twenty cubic 
centimetres of a centrifugated human pleural exudate intraperitoneally 
into a rabbit for five or six successive days. 

The Bremer- Williamson reaction of diabetic blood may be obtained 
a considerable time after death ; 4 the procedure is as follows : Forty 
cubic millimetres of water are placed in a small, narrow test-tube; to 
this are added twenty cubic millimetres of blood, one cubic millimetre 
of a one to six thousand aqueous solution of methylene blue, and forty 
cubic millimetres of liquor potassse. The test-tube is placed in boiling 
water for four minutes, at the end of which time, if the blood is diabetic, 
the blue color will have disappeared and a dirty-green color will have 
taken its place. Williamson obtained the reaction in forty-three cases 
of diabetes tested and thinks it is due to an increase of glucose in the 
blood. The reaction is of especial value in coma where urine cannot 
be obtained. 

Cryoscopy. — The determination of the osmotic pressure of liquids 
at their freezing-points is being studied extensively. The lowering of 

1 Vrtljschr. f. gerichtl. Med., 1902, p. 61. 

2 Ibid., Suppl.-Heft, 1902, p. 1. 

3 Spitalul., 1902, xxiii. p. 2>77- 

4 T. R. Brown, International Clinics, January, 1903. 



MEDICOLEGAL SUGGESTIONS 325 

the freezing-point is directly proportionable to the osmotic pressure 
of the liquid. Cryoscopy is a method introduced by Raoult, of Greno- 
ble, for the purpose of measuring the urinary toxicity as well as furnish- 
ing enlightenment upon the metabolic changes in the blood, cerebro- 
spinal fluid, and other fluids of the body. It has been found that the 
freezing-points of these fluids of the body present certain appreciable 
differences in certain diseases. The method has a wide field of useful- 
ness both in experimental research and in diagnosis and prognosis of 
disease. Those interested in the clinical applications of cryoscopy and 
their possible application to pathology are referred to Widal and Lesne's 
admirable paper in Vol. vi. of Cornil's Traite de pathologie generate, 
p. 661. Space permits but a single example of the possible use of this 
method. Revenstorf 1 determines the freezing-point of the blood from 
both sides of the heart, as more or less of the fluid in which an animal is 
drowned usually passes through the capillaries of the lungs and dilutes 
the venous blood. He concludes that the method, when positive, — i.e., 
when it can be shown that the freezing-point of the blood from the right 
side of the heart is higher than that of the blood from the left side, — 
is valuable as additional evidence of drowning, and is very easily car- 
ried out ; but decomposition rapidly removes any difference which may 
have existed, and the blood is not necessarily diluted during death by 
drowning. 

Cytology. — The different kinds of cells found under various con- 
ditions in the serous cavities form a most inviting field of study. 
Thus, in syphilitic hydrocele we have endothelium, in gonorrhceal 
hydrocele, marked polymorphonuclear leukocytosis, in tuberculous 
hydrocele, lymphocytosis, in mechanical hydrocele, few or no leuko- 
cytes. Naturally, the age of the process has much to do with the num- 
ber and variety of the cells. 

Toxicology. 2 — The presence of poisons in the animal economy 
may be recognized by clinical, chemical, pharmacological, and patho- 
logical methods. While we have chiefly to do with the latter method, 
the success of the chemist and the pharmacologist depends largely 
upon the procedures adopted for the preservation of material by the 
pathologist at the time of the performance of the autopsy.- There 
are certain poisons which may kill without leaving in the tissues any 



1 Mimchen. med. Wchnschr., No. 45, 1902, p. 1880. 

2 Much of the material in this section is taken from Robert's Lehrbuch der 
Intoxikationen, Stuttgart, 1902, and Glaister's Medical Jurisprudence, 1903. 



326 POST-MORTEM EXAMINATIONS 

specific alterations to be found post mortem, especially when the 
examination is postponed for several days. 

A poison is any substance which, when taken into the system and 
either being absorbed or by its direct chemical action upon the parts 
with which in contact, or when applied externally and entering the 
circulation, is capable of producing deleterious results. (Wormley.) 
Poisoning commonly results from alcohol, morphine, lead, arsenic, 
phosphorus, oxalic acid, carbolic acid, etc. ; from food (bromatotoxis- 
mus) ; from meat (kreotoxismus) ; from milk products (galactotoxis- 
mus) ; from fish and shell-fish (ichthyotoxismus, mytilotoxismus) ; 
and from grain (sitotoxismus) ; of the latter poisoning there are three 
kinds, — ergotism, lathyrism, and pellagra. 

It should always be remembered that conditions which we are apt 
to regard as being alone produced by strictly pathological processes 
are often due to poisons. Thus, toxic inanition may be produced by 
chronic poisoning with mercury, lead, arsenic, etc. ; fatty degenera- 
tion, by phosphorus, alcohol, Amanita phalloides, etc. ; calcification 
of the renal epithelium, by corrosive sublimate ; and amyloid degenera- 
tion, by repeated injections of turpentine. 

Suspicious undissolved foreign bodies may be found in the vomit 
and in the contents of the alimentary tract, as arsenic (white, metallic, 
and various salts), antimony, sulphide of antimony, mercury and its 
preparations, as calomel, oxid, and bichlorid, chrome salts, oxalates, 
cantharides, nux vomica beans, heads of matches, and parts of poison- 
ous plants. In one of my cases diagnosed as a heat-stroke, with a 
temperature of over no° F., the finding of leaves of datura stra- 
monium in the stomach led to the correct diagnosis. Morphine even 
when given hypodermically may be found in the stomach contents. 
Certain chemicals may be detected by odors coming from the body or 
from the various cavities when opened, as alcohol, ether, chloroform, 
aromatic oils, formalin, phosphorus, turpentine, nitrobenzol, benzene, 
wood alcohol, hydrocyanic acid, paraldehyde, camphor, chloral, car- 
bolic acid, nicotine, bromin, chlorin, iodin, ammonia, hydrochloric acid, 
oxalic acid, opium, sulphuretted hydrogen, etc. 

When the acidity or alkalinity of the gastric contents is abnor- 
mally increased, certain reagents are to be suspected, such as acids, 
alkalies, and potassium cyanid. The liver especially shows poisoning 
by phosphorus, antimony, arsenic, and toxins, while the kidney is 
affected by hemolytic and methaemoglobinic poisons, by oxalic acid. 



MEDICOLEGAL SUGGESTIONS 327 

oxamid, mercury, silver salts, preparations of cantharides, etc. The 
spectroscopic picture of the blood should always be obtained as soon 
after death or removal from the body as possible. The addition of 
a little distilled water is admissible in methgemoglobinsemia, but even 
here it is better at once to seal hermetically in glass tubes with exclu- 
sion of air as far as practicable. If the blood coming from veins is 
fluid and scarlet, suspect carbon monoxid poisoning; if a laky purple 
fluid, not changing on the exposure to oxygen, suspect cyanid. If 
the muscles of the abdominal walls are drawn and contracted spirally, 
we may suspect any of the instant poisons, as strychnine or potassium 
cyanid. I have for a long time had a bottle of blood from, a case of 
cyanid poisoning, and have many times exposed it to the air by re- 
moving the cork, yet it is apparently still in a perfect state of preser- 
vation. 

The left heart is found markedly contracted in death from over- 
doses of members of the digitalis group, veratrine, and barium salts. 
As already stated, the odor of the poison may sometimes be detected 
on exposing the brain. In one of my cases of ammonia poisoning a 
rod dipped in hydrochloric acid gave off fumes when introduced into 
the cranial cavity after removal of the brain. Much attention has 
been paid to the actions of poisons on the central nervous system, 
and the rapid diagnosis of hydrophobia by this method should not be 
forgotten. The joints are alleged to be inflamed after poisoning by 
colchicum. Testicular atrophy is said to be induced by the long- 
continued use of capsicum, solanus pseudocapsicum, and conium 
maculatum. 

The mucous membrane of the stomach is irritated and stained by 
many poisons, as sulphuric acid (black), nitric acid (yellow), oxalic 
acid (white), bromin (red), iodin (purple), and by a large number 
of metallic salts, as sulphid of arsenic (yellow), chromate of potas- 
sium (red), etc. I have, however, seen several cases of arsenical 
poisoning with but little inflammation of the gastric mucosa. 

Among the questions to be answered in every case of suspected 
poisoning are : Was death caused by a poison originating within or 
without the body? What poison caused death? Is the substance 
found by the chemist the poison which killed the person in whose body 
it was found? Might not the poison have been administered as a 
medicine? Is the poison present in such quantity as always causes 
death? Were there attendant circumstances which conduced to the 



328 



POST-MORTEM EXAMINATIONS 



fatal result? Was more than one poison given? How and when 
was the toxic substance administered? Could poison have been given 
and yet not be discovered? Was the fatal dose taken for purposes of 
suicide? Was it administered with the object of killing? Was it ad- 
ministered accidentally? Did the person for whom it was intended 
receive the poison? Could the toxic symptoms be simulated? Was 
cremation practised in order to destroy evidences of poisoning? Was 
there any motive for homicide? Are there any accomplices? What 
became of the vehicle in which the poison was administered? Was 
there any poison found ? Was any poison destroyed ? 

Nearly every toxicologist has his own classification of poisons. 
Thus, one divides them into mineral, vegetable, animal, and mechanical 
groups, another into irritants, narcotics, and narcotic irritants, a third 
into chemical and vital poisons, etc. All such divisions are arbitrary, 
as quickly becomes evident on attempting to place the various poisons 
in their proper subclasses. 



Inorganic 



Organic 



Irritant 



SCHEME FOR THE DIVISION OF POISONS. 

Irrespirable gases : carbon monoxid, coal gas, chlorin, bromin, 

hydrofluoric acid, sulphur dioxid, etc. 
Chemical : sodium hydrate, sulphuric acid, etc. 
Irritant : arsenic, antimony, mercury, phosphorus, etc. 

Irrespirable gases : chloroform, ether, formalin, etc. 
Chemical : carbolic acid, acetic acid, pyrogallic acid, etc. 

Vegetable : gamboge, colchicum, squill, etc. 

Animal : cantharides, etc. 

Narcotic : opium, hyoscyamus, belladonna, can- 
nabis indica, etc. 
Alkaloidal -| Sedative : digitalis, hydrocyanic acid, aconite, 
conium, etc. 

Excitomotor : strychnine, ergot, etc. 

Antiseptics : creolin, lysol, etc. 
Synthetical -J Antipyretics : antipyrin, acetanilid, etc. 

Hypnotics : sulphonal, trional. 

{Bacterial : toxins, hemolysins, cytolysins. 
Animal : snakes, scorpions, ptomaines, etc. 
Vegetable : ricine, abrine, etc. 



Acids. — Poisoning may be produced by mineral and vegetable 
acids, the corrosive action depending largely upon the strength of the 
acid at the time of its introduction into the body. Naturally, those 
parts are most affected which remain longest in contact with the acid. 



MEDICOLEGAL SUGGESTIONS 329 

The mucous membrane of the lips rarely escapes, and often the skin 
of. the lower lip is discolored. The mucous membranes of the mouth, 
oesophagus, and stomach are acted upon, and oedema of the glottis is 
common. The tissues are softened ; sometimes there is actual destruc- 
tion followed by necrosis, which may lead to perforation. Around 
these areas of corrosion is a more or less marked hemorrhagic inflam- 
mation. If the acid w r ere diluted, this inflammation is more marked 
and the corrosion less so. The blood in the external veins of the 
stomach is usually black. In all cases where death does not occur 
quickly, changes are seen in the parenchymatous organs, especially the 
kidneys. The color produced by different acids is somewhat charac- 
teristic. In carbolic acid poisoning the oesophagus is of a silver-gray 
color, the stomach is thrown into rugae, and the mucosa is of a rough, 
brownish, cracked appearance. The urine may be dark in color and 
smell strongly of phenol. In poisoning by sulphuric acid the mucous 
membrane of the upper intestinal tract is brownish or even black, due 
to the extraction of water from the tissues and the action of this acid 
on the coloring matter of the blood. It is often difficult or impossible 
to say whether perforation occurred during life or after death. The 
effects of hydrochloric acid are similar to those of sulphuric acid, but 
less marked, corrosive action on the skin being almost absent. Nitric 
acid imparts to the skin and mucosa a yellowish tinge, owing to the for- 
mation of picric acid. In oxalic acid and oxalate of potassium poison- 
ing white to grayish corrosion of the upper intestinal tract occurs, 
crystals of oxalates of lime being found in the blood and kidneys. Con- 
centrated acetic acid may also cause death. 

Aconite. — In aconite poisoning the physiological test should 
always be applied. No characteristic lesions are found post mortem. 

Alcoholism. — There are no really characteristic lesions. I. Gastro- 
intestinal Tract. — (1) Chronic hypertrophic gastritis may be followed 
by (2) atrophic gastritis with dilatation. (3) Hypertrophic or 
atrophic cirrhosis of the liver. Orth says, " Most drinkers have no 
cirrhosis of the liver, but a fat liver, and many with liver cirrhosis are 
not drinkers of alcohol." II. Vascular System. — ( 1 ) The heart is usu- 
ally enlarged and its muscle often thin, fatty, and friable. (2) The 
blood-vessels are frequently sclerosed, especially those arteries exposed 
to much strain. (3) The venules of the cheek and nose are often dis- 
tended. III. Central and Peripheral Nervous System. — (1) The pia- 
rachnoid is thickened, with wasting of its convolutions. (2) The blood- 



330 POST-MORTEM EXAMINATIONS 

vessels are thickened, tortuous, and may show miliary aneurisms. ( 3 ) 
The motor nerves of the muscles are sometimes altered (multiple neu- 
ritis). IV. Genito-urinary Tract. — (1) The kidneys are enlarged, 
cyanotic, and indurated. ( 2 ) The bladder is thickened and often shows 
signs of chronic cystitis. 

Alkalies and Caustic Salts. — Alkalies, potash, soda, and am- 
monium hydrate act much the same as acids except that the involved 
areas are brown and less brittle. The epithelium is shed in threads and 
there are ecchymotic folds of the mucosa. Capillary bronchitis is com- 
mon ; so is stricture of the oesophagus in patients who recover. In one 
of my cases cancer followed at the seat of stricture due to the accidental 
drinking of lye. 

Antimony. — Poisoning is usually due to tartar emetic. The mu- 
cous membrane from the mouth to the duodenum inclusive is usually 
inflamed, and often ulcerated and covered with stringy mucus. In 
chronic cases there is considerable emaciation ; chemical tests will deter- 
mine its true character. 

Arsenical Poisoning. — This may be: (a) Acute. (&) Subacute. 
(c) Chronic. In acute arsenical poisoning there is generally a marked 
gastro-enteritis, which differs in severity according to the amount taken. 
The mucous membranes are intensely swollen, cedematous, and present 
small emphysematous bullae or diphtheritic exudate. Petechial erup- 
tions may occur in both the stomach and intestines. The contents of the 
stomach are usually of a brownish color. In subacute arsenical poison- 
ing or where large doses have been taken, patches varying in size from 
a dime to a silver dollar, consisting of an opaque white, yellowish, or 
even violet coagulated lymph mixed with arsenous acid and firmly fixed 
to the mucous membrane, with signs of intense inflammation around 
them, may be found in the bowels. White spots of arsenic are some- 
times discovered between the rugae, and fatty degeneration of the intes- 
tinal epithelium and of the viscera is also present. Chronic arsenical 
poisoning is characterized by wide-spread fatty degeneration, affecting 
especially the heart, liver, spleen, and kidneys. Marked changes are 
also found in the voluntary muscles, which show wasting, fatty degen- 
eration, and often cirrhosis. Trophic changes are common, such as 
overgrowth of hair and nails, both of which are harsh and brittle. The 
skin is harsh, dry, and frequently shows eruptions. Although arsenic 
is rapidly eliminated from the body, enough usually remains for pur- 
poses of identification. The urine should always be saved. The white 



MEDICOLEGAL SUGGESTIONS ^l 

material should be examined microscopically for the octahedral crys- 
tals, and in England for soot and indigo, as the law there requires the 
retailing pharmacist to mix his arsenic previous to selling with one or 
the other of these substances. There are no characteristic lesions post 
mortem. It is a disputed question as to whether bodies keep a longer 
time after death in arsenical cases. The manifold ways in which arsenic 
may accidentally get into the system and thus cause death should always 
be remembered. From wall-paper it enters the system as diethylarsin. 
In England there were recently thousands of cases of arsenical poison- 
ing, with many deaths, due to the drinking of beer made from glucose 
containing arsenic. Gautier, a celebrated French chemist, claims, con- 
trary to general belief, that arsenic is a normal weighable constituent 
of the thyroid gland. Rough-on-rats and Paris green are favorite 
preparations for use by would-be suicides. 

Atropine. — Fatal cases of atropine poisoning, either suicidal or 
homicidal, are rare, though accidental poisoning by the Datura stra- 
monium is common. Death is caused by asphyxiation, the symptoms 
resembling those seen in heat-exhaustion. Careful search should be 
made in the stomach for any seeds, leaves, or berries. 

Chloral Hydrate. — Urine should always be preserved for chem- 
ical examination. Chloral is often taken with other drugs, as morphine, 
and after a debauch ; this renders it difficult or even impossible to tell 
just what the effect of the chloral on the system actually is. 

Chloroform and Ether Poisoning. — The saying of Tait, that 
the coroner has to do with chloroform death while the physician signs 
the death certificate in ether cases, is well known. Fright may have 
something to do with death in these cases. Signs of asphyxia are usu- 
ally present and the characteristic odor is capable of determination. But 
then the ether may have been given, yet death be due to other causes. 

Cocaine Poisoning. — At postmortem the heart is found in diastole 
and the nerve-centres are said to be congested. Cocaine should be 
tested for before making the diagnosis. 

Copper. — The lining walls of the stomach often have a bluish or 
greenish tinge. On the application of ammonia the coloration deepens 
into a darker shade of blue, or the green is converted into this color. 
Part of the toxic effect of the arsenite of copper is due to the copper. 
Zinc, tin, and barium salts may also cause death in an overdose. 

Ergot Poisoning. — After death from ergot poisoning the arteries 
are found contracted and the abdominal viscera inflamed. In the 



332 



POST-MORTEM EXAMINATIONS 



chronic form the posterior columns of the cord are sclerosed and micro- 
scopical sections resemble those characteristic of locomotor ataxia. 

Formaldehyd. — Bock * reports a case of poisoning by formalin in 
an imbecile twenty-six years of age. From one to three ounces of a 
four per cent, solution were taken. Death occurred thirty-two hours 
later. The stomach was necrotic, dark, tough, and cut like leather. 
Kliiber 2 and Zorn 3 have also reported cases of poisoning by formalin. 

Hydrocyanic Acid and Cyanid of Potassium Poisoning. — The 
mucous membrane of the stomach is markedly and uniformly injected 
and congested. The odor of bitter almonds is detected at once on open- 
ing the abdomen. It should always be remembered that, if the post- 
mortem is not made for thirty-six hours after death, all the hydrocyanic 
acid may be converted into formic acid. The blood is dark and fluid 
and keeps for a long time without undergoing decomposition. 

Illuminating Gas and Carbon Monoxid Poisoning. — These 
two poisons are not quite alike in their action, though the poisonous 
properties of illuminating gas are largely due to the considerable 
amount of carbon monoxid which it contains, especially if of the 
variety known as " water gas." The body may appear quite life-like, 
with even a rosy hue upon the cheeks. After death the blood retains 
its bright cherry-color for some time, seen especially in the brain, and 
when shaken forms a froth of a violet color. All color reactions should 
be studied at once, before giving time for the oxygen of the air to act 
upon the blood. The skin and internal organs, as also the patches of 
post-mortem congestion, are bright red. The lungs are frequently con- 
gested. Carbon-monoxid haemoglobin produces two absorption bands 
near D and E like oxyhemoglobin, the latter, however, being reduced 
by the addition of the sulphid of ammonium. The blood should not be 
taken from the heart for this purpose, but from the smaller vessels in 
the muscles. It is well to remember that the spectroscopic test may 
even be secured several months after death in favorable circumstances. 
To detect a small quantity of carbon monoxid in the air of a room 
fresh normal blood is added to distilled water until the latter is faintly 
tinged ; about five cubic centimetres are placed in a flask of some one 
hundred and fifty cubic centimetres' capacity and agitated several 



1 Fort Wayne Medical Journal Magazine, July, 1899, p. 249. 

2 Munchen. med. Wchnschr., October 9, 1900. 

3 Ibid., November 13, 1900. 



MEDICOLEGAL SUGGESTIONS 333 

minutes in the suspected atmosphere; if the noxious gas be present, the 
liquid assumes a rose tint and gives the characteristic spectrum. In 
cases which live a day or so and then die bilateral softening may occur 
in the region of the inner capsule and the caudate and lenticular nuclei. 
The victim may die from a dose of some other poison taken with suicidal 
intent before turning on the gas. 

Lead Poisoning. — In acute lead poisoning there is marked gastro- 
enteritis, and the bowels usually contain a large amount of blackish 
fluid. The kidneys show evidence of acute diffuse nephritis. In chronic 
lead poisoning the distinctive features are a marked fatty degeneration 
affecting the muscles, kidneys, spleen, and liver. There is often marked 
cirrhosis with atrophy of these organs. Arteriosclerosis with hyper- 
trophy of the heart is also marked. Distinct gouty deposits are often 
found, particularly about the big toe. The brain is sometimes shrunken 
and dry, the blood-vessels being constricted; or these organs may be 
pale and extremely firm, or pale and cedematous, as in cases of uraemia. 
The small intestines may show areas of extreme contraction. 

Mercurial Poisoning. — The mucous membranes of the gastro- 
intestinal tract, especially the small intestine and caecum, show exten- 
sive desquamation, with hyperaemia, ecchymoses, and grayish-white 
eschars. The bowel generally contains large quantities of liquid of a 
yellowish-brown or blood-stained character. The macroscopic appear- 
ances are those of dysentery. In some acute cases decalcification of the 
bones occurs, with a deposit of lime elsewhere in the body, especially 
in the kidneys. The number of mercurial salts is legion, many forming 
with albumin an insoluble albuminate of mercury. Chronic cases of 
poisoning occur, ulcerative stomatitis being one of the chief lesions. 

Methyl Alcohol. — Blindness or impairment of vision may occur 
not only from the ingestion of wood alcohol, but also from inhalation 
of its fumes, as methyl alcohol seems to have a predilection for the 
retina and the optic nerve. A number of cases of poisoning from this 
source have recently occurred in New Orleans from the use of a pro- 
prietary medicine. 

Nitrobenzol Poisoning. — Besides the odor of the artificial oil of 
bitter almonds, the blood and muscles are of a brownish color and the 
mucous membrane of the stomach is ecchymotic and injected. The body 
is cyanosed and of a leaden hue. 

Opium Poisoning. — In acute poisoning there is nothing to distin- 
guish the condition of the brain from that in other cases of cerebral 



334 



POST-MORTEM EXAMINATIONS 



congestion. Extreme passive congestion of the bases of the lungs may- 
take place, as in cerebral apoplexy (Osier). Cases of uncomplicated 
chronic poisoning are rare. The most important lesion is fatty degen- 
eration of the heart. The liver may show similar changes. If lauda- 
num has been used, the characteristic odor may be determined. I know 
of no drug which is more apt to escape detection at the postmortem 
than morphine, as there are absolutely no characteristic lesions and 
chemical analyses are difficult and at times inaccurate. It seems strange 
that one of the most common and easily accessible poisons is thus so 
hard to detect. The pupillary reaction is of no value after death, and 
the clotting of blood in the right heart is by no means constant. 

Pellagra Poisoning. — The lesions found are in the posterior col- 
umns and the crossed pyramidal tract. The cells in the anterior horn 
are deeply pigmented, and pigment is found in the internal organs and 
the skin. The brain presents general wasting; the ventricles are 
somewhat distended and contain an excess of fluid. 

Phosphorus Poisoning. — In acute phosphorus poisoning the 
gastro-intestinal tract, especially in the stomach, shows an intense 
degree of inflammation. Hemorrhages are common and the stomach 
may contain grumous (coffee-ground) blood. The mucous mem- 
brane is the seat of numerous ecchymoses as well as more or less exten- 
sive necroses. The skin, the serous membranes, the muscles, and the 
adipose tissues all show numerous small hemorrhages. The blood is 
liquid and dark. The skin is jaundiced. The liver, in the early stages 
increased in size, soon — in from ten to fourteen days — becomes small 
(from one-half to one-third of the normal bulk), the capsule is wrin- 
kled and shrunken, the color is pale yellowish, and on section the organ 
presents yellowish patches in the midst of which are areas of deep 
congestion. Drops of fat are seen upon the knife. The kidneys are 
large, their cortex pale, and the medullary portions congested. The 
epithelium often shows marked granular degeneration. As a rule, the 
spleen is not markedly altered. In chronic poisoning by phosphorus 
wide-spread fatty degeneration is the rule. In cases of workers in 
phosphorus having defective teeth, necrosis of the jaw is not uncom- 
mon. It is the yellow phosphorus that is poisonous and not the red 
variety. Bug exterminators often contain phosphorus. The coating 
from the ends of matches is often taken with suicidal intent. 

Potassium Chlorate Poisoning. — The blood has the color and 
consistence of chocolate, the oxyhemoglobin having been reduced to 






MEDICOLEGAL SUGGESTIONS 335 

methsemoglobin. There is usually a hemorrhagic nephritis, especially 
of the glomeruli. 

Ptomain and Toadstool Poisoning. — Such cases are of especial 
interest to the toxicologist, as the symptoms produced and the lesions 
found at the postmortem are similar to those caused by many alkaloidal 
and irritant poisons, and the possibility of the case under considera- 
tion in a trial being due to one or other of these substances is always 
suggested by the defence. 

Silver Nitrate Poisoning. — I have been fortunate enough to 
see one case of this rare form of poisoning. The darkening of the 
necrosed mucous membrane on exposure to light was the chief diag- 
nostic point. The child had an inspiration pneumonia. 

Snake Poisoning. — After death caused by cobra bite rigor mortis 
occurs as usual. The areolar tissue in the region of the bite is infil- 
trated with a pinkish fluid and the vessels are injected. The blood 
presents no demonstrable change. The veins of the pia mater are 
usually engorged, and the ventricles often contain turbid fluid. The 
lungs are generally congested and the lining of the bronchi injected. 
The appearance of the kidneys varies from normal to one of intense 
congestion. After death following the bite of an Australian snake 
the appearances are much the same as those just described. The blood 
may contain soft coagula, the lungs are sometimes the seat of hemor- 
rhages, and the mucous membranes may be intensely congested and 
hemorrhagic. The central nervous system shows engorgement of the 
blood-vessels. At autopsy, after the bite of a viperine snake, the 
region of the wound is seen to be the seat of intense oedema and extra- 
vasation of blood, and the underlying muscles are frequently disorgan- 
ized and even diffluent from the latter cause. Hemorrhages may also 
be found in any of the organs and along the alimentary tract. The 
kidneys are acutely congested or hemorrhagic. The blood is fluid. 

Strychnine Poisoning. — Rigor mortis is intense and persistent 
and the blood is dark and fluid as in asphyxia. Be sure to save the 
urine if any be present; a frog placed in it will have convulsions, even 
if but a small amount of strychnine be present. 



CHAPTER XXVIII 

THE PRUSSIAN REGULATIONS FOR THE PERFORMANCE OF AUTOPSIES 
IN MEDICOLEGAL CASES 

The Prussian regulations governing the performance of postmor- 
tems by the legally appointed officers of the court are of great historic 
interest, as they bear the imprint of Virchow, and, though put in force 
February 13, 1875, are still observed throughout Prussia. These regu- 
lations also form the basis of similar statutes in other German states 
and in many countries throughout the world ; indeed they are so well 
defined that it is advisable, though one may chafe under their appar- 
ently unnecessary restrictions, to depart from them only in exceptional 
instances. This is especially the case if the one performing the autopsy 
is a beginner in medicolegal work. 

I. GENERAL CONSIDERATIONS. 

\ 1. According to the present law, an examination of a corpse 

The Physicians £ or medicolegal purposes may be made only in the presence of 

making the Autopsy, . , , , , ,.-. , . , < , , 

and their Duties ^ magistrate by two practitioners, one of whom should be a 

state-appointed physician and the other a district surgeon. Those 

performing the autopsy are empowered with the duties of medicolegal experts. If 

doubt should arise in the technical performance of the autopsy, the physician or 

his deputy decides the question under consideration conditionally upon the right of 

the surgeon to state upon the protocol his dissenting opinion. 

$ 2. The medical officers are permitted to appoint substitutes 
only when unavoidably detained from the performance of their 

medicolegal duties. If possible, the deputy chosen is to be a physician who has 

passed his pro physicatu examination. 

Time after Death $ 3- As a ru ^ e ' postmortems should not be performed until 

at which the Post- twenty-four hours after death ; the mere inspection of a corpse, 
mortem is to be however, may be made earlier than this, 

performed 

\ 4. As a rule, post-mortem examinations must not be neg- 

The Examination of lected nor their performance refused by the legally appointed 
Decomposed Bodies physicians because of the presence of decomposition, for even in 
a badly decomposed cadaver abnormalities and injuries to the 
bones may still be detected; many facts of value in the identification of a body 
may be ascertained, such as the color and appearance of the hair, the absence of 
limbs, etc. ; and substances which have entered the body from without may be 
discovered, as well as unsuspected pregnancy or poisoning. On the same grounds, 
when for one reason or another the advisability of disinterring a body is under 
consideration, the physicians are to approve of such exhumation without regard to 
the time which has elapsed since death. 
336 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 337 

\ c. The legally appointed physicians are to be careful to have 
, , „ 7 ' . , . , ... Instruments 

the following instruments in readiness and in good condition : 

from four to six scalpels, of which two are to possess a straight and two a 
rounded cutting edge ; one razor ; two strong cartilage-knives ; two forceps ; 
two double hooks ; two pairs of scissors, — the stronger pair should have one blade 
pointed and the other rounded, while the smaller pair should possess one probe- 
pointed and one sharp-pointed blade; one enterotome ; one injecting nozzle with 
stopcock ; one coarse and two fine sounds ; one saw ; one chisel and one hammer ; 
one costotome ; six curved needles of different sizes ; one pelvimeter ; a one-metre 
rule divided into centimetres ; one measuring-glass divided into one hundred, fifty, 
and twenty-five cubic centimetres ; one pair of scales capable of weighing up to 
ten pounds ; one good magnifying-glass ; blue and red litmus paper. The cutting 
instruments must be perfectly sharp. Those performing the postmortem are recom- 
mended to have ready for use a microscope with two objectives, so as to be able 
to magnify at least four hundred diameters, and the required instruments, glass- 
ware, and reagents necessary for the preparation of microscopical slides. 

\ 6, A sufficiently large well-lighted room is to be chosen for the 

autopsy, and all possible care is to be taken in the selection of Place for the Autopsy 

a suitable place on which to lay the body and in the avoidance and its Lighting 

of all disturbing surroundings. Post-mortem examination by 

artificial light, except where postponement is impracticable, is not allowed ; should 

it be done, the reason therefor must be expressly stated in the protocol ($ 27). 

§ 7. If the body be frozen, it must be brought into a heated „ ,. 

1 * * 1 -1 1 11 rr - 1 Frozen Bodies 

place and the autopsy postponed until the cadaver has sufficiently 

thawed ; the employment of warm water or other warm articles to hasten the thaw- 
ing process is forbidden. 

§8. If possible, when for any reason the body is moved, espe 

daily if transported from one place to another, there is to f corpses ^ 

be no excessive pressure made upon any of the individual parts, 

nor any marked departure from the horizontal position of the organs in the larger 

cavities. 

II. TECHNIC OF THE POSTMORTEM. 



$ 9. Those performing the postmortem must hold steadfastly 
to the object in view, which is to make the investigation with 
accuracy and completeness. All important findings must be 
shown to the magistrate by the obducents before they are entered in the protocol 



Medicolegal Aspects 
of the Postmortem 



\ 10. In those cases in which this appears to be necessary, the Duties of the Obdu- 
examiners are required, as early as feasible before the perform- cents in regard to 
ance of the autopsy, to ask the magistrate for permission to visit the Ascertainment 
11 1111 r ■. 1 1 .of Special Circum- 

the place where the body was found, and they are to ascertain stances connected 
the position in which the body was discovered and be given an with the Case 
opportunity to examine the clothing which the deceased wore und er Investigation 
at the time of his or her death. As a rule, however, it is sufficient for them to 
await the solicitation of the magistrate to undertake these investigations. They are 
also obliged to ask for information from the magistrate in regard to any disclosures 
which might be of use to them in the performance of the autopsy or in helping 
them to make up their deductions therefrom. 

22 



33§ 



POST-MORTEM EXAMINATIONS 



$ ii. In cases in which a doubtful finding is to be quickly 
Examinations anc * definitely settled, — as, for example, the differentiation be- 

tween a fluid containing blood and one which is merely stained 
with haematin, — a microscopical examination is to be then and there undertaken. 
When circumstances render this impossible or when difficult microscopical investi- 
gations which cannot be made at once are required, — as, for example, of certain 
tissues of the body, — portions of such tissue are to be preserved under legal pro- 
tection and as quickly as possible thereafter to be thoroughly examined. It is 
to be distinctly stated in the report of such findings when the examinations were 
performed. 

\ 12. The postmortem is divided into two main parts : A. Exter- 
The Postmortem : its , . . , . N _ T , . . , 

two main divisions examination (inspection). B. Internal examination (sec- 

tion). 

External §13. In the external inspection of the body its appearance in 

Examination general and that of its individual parts in particular are to be 

noted. In this general examination of the body the following 
points, if possible, are to be brought out and recorded. 1. Age; sex; size; devel- 
opment; general condition of nutrition; any signs of previous illnesses, — e.g., 
ulcers of the foot ; special abnormalities, — e.g., moles, scars, tattoo markings ; in- 
crease or absence of limbs. 2. The signs of death and the changes that have 
already taken place from decomposition. 

After removal by washing of any contaminations of the body in the way of 
blood, faeces, dirt, etc., record is to be made of the presence or absence of post- 
mortem rigidity ; the general color of the skin of the corpse ; the manner and 
degree of coloration and discoloration brought about by putrefaction ; and the 
color, situation, and extent of any areas of hypostatic congestion, which are to be 
incised and then examined and described, in order to prevent their being mistaken 
for extravasations of blood. 

The following particulars are to be considered in the study of the individual 
parts. 1. In unidentified persons, the color and other appearances of the hair 
(head and beard), as well as the color of the eyes. 2. The possible presence of 
foreign substances in the normal openings of the head, the arrangement of the 
teeth, and the situation and appearance of the tongue. 3. An examination is next 
to be made of the neck, the breast, the abdomen, the back, the anus, the external 
genitalia, and finally of the limbs. 

If an injury is found in any of these parts, its shape, situation, and direction 
with relation to fixed points of the body are to be described and the length and 
breadth of the injury given in the metric system. In solution of continuity of 
tissue, probing is, as a rule, to be avoided in the external inspection, because after 
the internal examination of the body and of the injured spot the extent of the 
injury is to be described. Should the obducents decide that the introduction of 
a sound is necessary, this procedure is to be done with great care and special 
mention of the reason therefor is to be made in the protocol (§ 27). When wounds 
are present, a description of their borders and the adjacent tissues is to be given, 
and after such an examination and description of the lesions in their original con- 
dition the same are to be enlarged in order that the appearance of the borders and 
of the bottom may be disclosed. As to wounds and injuries which clearly did not 
conduce to, originate from, or have any connection with death, — for example, mark- 
ings produced in the endeavor to restore life, gnawing by animals, and the like, — 
a summary description of the findings is sufficient. 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 339 

§ 14. In the internal examination the three main cavities of the 
body— the cranial, the thoracic, and the abdominal— are to be ^ n ^^ aina " 
opened. Opening of the vertebral column or of the individual considerations 
joints is not to be omitted in cases where important findings 
might be secured thereby. When there is a definite suspicion as to the cause of 
death, the postmortem is to be commenced with that cavity in which the chief 
changes are suspected. Otherwise the head is to be examined first, the thorax 
next, and the abdominal cavity last. 1 The situation of the organs found in each 
of the above-named cavities is first to be determined, then the color and the appear- 
ance of the exposed surfaces. The presence is to be noted of any unusual con- 
tents, such as foreign bodies, gases, fluids, or clots, and in the last two cases 
measured and weighed, and finally each individual organ is to be examined exter- 
nally and internally. 

I 15. When no injuries are present, the opening of the cranial „ . , „ . 

. . ,. . . , , . .... , Cranial Cavity 

cavity is accomplished by making an incision from one ear to the 
other directly over the skull, after which the skin-flaps are displaced forward and 
backward. (In case such injuries are found, they should be as much as possible 
circumvented by the knife, thus giving rise to a different procedure.) As soon as 
the appearance of the soft parts and the surface of the bony cranium has been de- 
scribed, the latter is cut through with a saw by a circular incision, and the calvarium, 
the inner table, and the part removed are described. The external surface of the 
dura mater is next examined, the longitudinal sinus opened, and its contents esti- 
mated. The dura mater is then to be separated on one side and laid back, and the 
internal surface of the same described, as well as the appearance of the exposed 
pia mater. After this has been done on the opposite side, the brain is to be removed 
in as perfect a condition as possible, and the presence of abnormal contents in the 
skull is to be noted, and the appearance of the dura and pia mater at the base and 
sides of the skull and the condition of the large arteries are to be described. After 
the opening of the transverse sinuses (and, in case reason therefor exists, of the 
remaining sinuses), the size and shape of the brain are noted and an examination 
is made of its individual parts by means of a series of well-ordered incisions. Such 
parts include both cerebral hemispheres, the large ganglia (optic thalamus and 
corpus striatum), the corpora quadrigemina, the cerebellum, the pons Varolii, and 
the medulla oblongata, in the description of which are to be included especially the 
color, the fulness of the vessels, the consistency, and the structure. In addition, the 
tissue and the vessels of the choroid plexus are always to be described. The size 
and the contents of the different ventricles as well as the appearance and fulness of 
the different vascular plexuses in the individual sections of the brain are constantly 
to be kept in mind, and especial note is to be made of the presence of any clotted 
blood outside of the blood-vessels. The dura mater over the base of the skull and 
the sides is then to be removed and the condition of the bones in these regions 
described. 

\ 16. When it is required to open the internal portions of the 

j- -1 -iii • ,,1 J-.L Face, Parotid 

face, to examine the parotid gland, or to inspect the auditory Gland and Ear 

apparatus, the initial incision extending over the skull is continued 

behind the ear and down the neck, and the skin, for appearances' sake, is dissected 

1 As to autopsies on the new-born see §§23 and 24. 



340 



POST-MORTEM EXAMINATIONS 



away from beneath towards the part to be investigated. In this examination special 
attention is to be paid to the condition of the large arteries and veins. 

§ 17. The opening of the spinal column (§ 14) is usually made 
and Cord from behind, the skin and the subcutaneous fatty tissue being cut 

directly over the spinous processes and the musculature dissected 
away from the side of the latter and from the vertebral arches. During this exam- 
ination hemorrhages, lacerations, and similar changes, especially fractures of bones, 
are to be carefully searched for. Then a chisel, or, if one is at hand, a vertebral 
saw (rhachiotome) is used for the purpose of separating the spinous processes with 
the adjacent portions of the arches throughout their entire extent. When they are 
removed, the external surface of the dura mater, which is now brought into view, 
is examined. It is next to be carefully opened by means of a longitudinal incision, 
and any abnormal contents, especially fluid or extravasated blood, are to be described, 
also the color, appearance, and similar characteristics of posterior portions of the 
pia mater, and by means of a gentle passage of the fingers over the spinal cord its 
degree of consistency is to be determined. Next, on both sides, by means of a 
longitudinal incision the nerve-roots are cut through ; then with one hand the lower 
end of the spinal cord is carefully grasped, and, after dividing the anterior attach- 
ments one after another, its upper end is finally drawn out of the occipital foramen. 
In all these proceedings special care should be taken not to make pressure on the 
spinal cord or to bend it. When the cord has been removed, the anterior surface 
of the pia mater is to be examined ; next the external appearance of the cord as 
to size and color is to be described, and finally, by a considerable number of trans- 
verse incisions with a sharp and thin knife, the internal appearance of the spinal 
cord, both as to its white and its gray matter, is to be noted. Finally the dura 
mater of the vertebral bodies is to be removed, and they are to be examined in 
order to determine if there have been any hemorrhages, injuries, or changes in the 
bones or in the intervertebral discs. 

§ 18. The neck and the thoracic and abdominal cavities usually 
Neck, Thoracic and are p e ned by means of a single long incision from the chin to 

Gener™i n cl>rfs?dera- S ' the pubic s y m P h y sis > Passing to the left of the navel. Most 
t j ons commonly the incision in the abdomen is made deep enough to 

penetrate the abdominal cavity, care being taken to avoid injuring 
the organs contained therein. This is best begun by cutting a small nick in the 
peritoneum, at the same time observing whether any gas or fluid escapes. One 
finger is introduced into the opening and then another, the abdominal wall is ele- 
vated from the intestines, and the further opening of the peritoneum is made 
between the two fingers. The situation, the color, and other appearances of the 
intestines are to be immediately observed, as well as any abnormal contents within 
them, and the condition of the diaphragm is to be determined by palpation of its 
under surface. 

The examination of the abdominal organs is to be proceeded with at this time 
only where a strong suspicion exists that the cause of death may be found within 
the abdomen ( \ 14) . As a general rule, the thorax is to be opened and inspected 
before any further scrutiny of the abdominal cavity. 

\ 19. In opening the thoracic cavity the soft parts of the breast 
Thoracic Cavity are dissected slightly beyond the junction of the osseous and 

cartilaginous portions of the ribs. Next with a strong knife 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 



341 



the cartilages are incised a few millimetres within their attachment to the ribs, 
care being taken to avoid cutting the lungs or the heart. If the cartilages be ossi- 
fied, the ribs are to be separated with a saw or a costotome somewhat beyond the 
cartilaginous junction. The attachments of both clavicles to the sternum are then 
separated by vertical semicircular sections, and the junction of the first rib, be it 
cartilaginous or ossified, is loosened with the knife or costotome, great care being 
taken to avoid injuring the vessels which lie beneath. The diaphragmatic attach- 
ments along the line of incision are severed close to the false cartilages and the 
ensiform process. The sternum is turned upward and the mediastinum is cut 
through, with careful avoidance of any injury to the pericardium or the large 
blood-vessels. When the sternum has been separated, the condition of the pleural 
cavity is to be determined, especially as to any abnormal contents, which are to be 
measured and their characteristics described ; also the extent and the appearance 
of any portions of the lung which are in view. If any vessels have been injured 
in the removal of the breast-bone, they are to be tied or a sponge is to be placed 
beneath the bleeding points to catch the blood which if it were allowed to enter 
the pleura would later obscure the observation of the parts therein. The condition 
of the mediastinum and especially that of the thymus gland are to be noted, as well 
as the appearance of the large blood-vessels lying outside of the pericardium, which 
are not yet incised. The pericardium is next to be opened and examined and the 
exterior of the heart inspected. Before the heart is incised or removed from the 
body its size, the filling of the coronary vessels and its individual cavities (auricles 
and ventricles), its color, and its consistency (rigor mortis) are to be estimated. 
While the organ is still in its natural position, the ventricles and auricles are to 
be separately opened and the contents of each chamber determined as to their 
amount, condition, coagulation, and appearance, and the dimensions of the auriculo- 
ventricular openings are to be ascertained by the introduction of two fingers through 
the auricle. The heart is then to be removed from the body and the condition of 
the arterial vessels tested, first by filling them with water and next by incising 
their walls. Finally the color and exact appearance of the heart muscle are to be 
described. In every case wherein it is suspected that extensive changes — e.g., fatty 
degeneration — have occurred in the muscular tissue a microscopical investigation is 
to be made. To this examination belongs that of the large vessels, with the single 
exception of the descending aorta, which is to be examined after the lungs have 
been excised. A minute inspection of the latter is not undertaken until they have 
been removed from the thoracic cavity. During this procedure great care is to be 
taken to avoid tearing or pressing upon the tissues. Should there be any extensive, 
especially old, adhesions, these are not to be broken down, but the attached pleura 
at this point is to be excised at the same time. When the lungs have been removed, 
their surface is again to be carefully examined for recent changes, so that nothing 
shall be overlooked, — for example, the commencement of inflammatory exudations ; 
then the air contents, color, and consistency of the individual lobes are to be given. 
Finally large, smooth sections are to be made in order to determine the appearance 
of the cut surface and the air, blood, and fluid contents, as well as any solid con- 
tents of the air-vesicles, the condition of the bronchi and the pulmonary arteries, 
the latter being examined with special care to detect any obstructions, etc. For this 
purpose the air-passages and the large pulmonary vessels are to be opened with 
scissors and their finer ramifications followed out. When the suspicion arises that 
foreign materials are present in the air-passages or substances are therein found the 
nature of which cannot with certainty be determined by the naked eye, a micro- 
scopical examination is to be made. 



3 4 2 POST-MORTEM EXAMINATIONS 

$ 20. The examination of the neck may, according to the nature 
of the case, be made either before or after the opening of the 
thorax or the removal of the lungs. The obducents may also sever the larynx and 
the bronchus before the further inspection of the remaining parts when it seems to 
them especially desirable so to do, as is the case in drowning or hanging. As a 
rule, it is wise next to examine the large vessels and the nerve-trunks, then the 
larynx and trachea, by means of an anterior incision, and note their contents. If 
this observation should appear to be of especial importance, it is to be made before 
the removal of the lungs, which are at the same time to be carefully pressed upon 
to see if any fluid, etc., arises in the trachea. The larynx, the tongue, the velum 
palati, the pharynx, and the oesophagus are to be removed together; the individual 
parts are to be carefully opened and their contents and the mucosa thoroughly 
examined. At the same time the thyroid, the tonsils, the salivary glands, and the 
lymph glands of the neck are to be observed. In every case where injuries of the 
larynx or of the bronchus have been found or important changes therein are sus- 
pected, the air-passages are to be opened after their removal from the body and 
they are then to be examined from their posterior aspect. In cases of hanging or 
in suspicious cases of strangulation the carotids are to be opened in order to ascer- 
tain whether or not their inner coats have been injured. This examination is to 
be undertaken while the vessels are still in their natural situation. Finally the condi- 
tion of the cervical vertebrae and of the deep musculature is to be determined. 

$ 21. The abdominal cavity and its viscera are now to be critically 
Abdominal Cavity inspected in such order that the removal of one organ does not 

prevent the exact determination of its relations to another. Thus, 
the duodenum and the gall-ducts are to be examined before the scrutiny of the liver. 
As a rule, the following order of examination commends itself : I. Omentum. 2. 
Spleen. 3. Kidneys and adrenals. 4. Bladder. 5. Organs of generation: in the 
male, prostate, seminal vesicles, testicles, and penis with the urethra ; in the female, 
ovaries, Fallopian tubes, uterus, and vagina. 6. Rectum. 7. Duodenum and stomach. 
8. Gall-ducts. 9. Liver. 10. Pancreas. 11. Mesentery. 12. Small intestine. 13. 
Large intestine. 14. The large blood-vessels in front of the vertebral column, whose 
condition as to blood contents is to be ascertained and noted. 

In every case the spleen is examined in regard to its length, 

breadth, and thickness, not while held in the hand, but when 

placed on a solid surface and without pressure by the instrument used in measuring. 

It is to be divided throughout its entire length, more incisions being made in different 

directions if diseased areas are suspected. 

Each of the kidneys is to be removed after cutting vertically 
Kidneys . ..,..,,. 

through the peritoneum externally and behind the ascending or 

descending colon, which is shoved back. The capsule is then incised longitudinally 
through its convex border and slowly peeled off, and the exposed surface of the 
kidney is examined in regard to size, form, color, condition of blood, and other 
appearances. Next a longitudinal incision is made through the entire kidney to its 
pelvis, and the cut surfaces are washed with water and described, in which descrip- 
tion medullary and cortical substances, vessels, and parenchyma are to be distin- 
guished. 

The pelvic organs (bladder, rectum, and genitalia in connection 
Pelvic Organs therewith) are removed en masse, but preferably the bladder is 

opened and its contents are examined while it is in its natural sit- 
uation. After their removal these organs are again inspected, the reproductives 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 343 

being examined and opened last. The slitting of the vagina is to precede that of the 
uterus. In puerperae the venous and lymphatic vessels both in the internal surface 
of the uterus and in its walls and adnexa require special attention as to their width 
and contents. 

When their external condition has been determined, the stomach 
and duodenum are with a pair of scissors opened in their natural Duodenum 
situation, the duodenum on its anterior surface and the stomach 
along its greater curvature. After a careful inspection of their contents, the per- 
meability and the presence of any matter in the opening of the gall-passages are 
determined and these parts are then removed for further examination. 
The liver is first described externally in its natural situation, and 
after its secretory ducts have been examined (as mentioned in 
the preceding paragraph) the gland is excised. Smooth incisions are now made 
through the entire length of the organ and its capacity for blood and the condition 
of the parenchyma determined. In the description a short account is always to be 
given of the general relations of the individual lobes, noting especially the relations 
of the inner and outer portions. 

The small and large intestines, after their individual portions 
have been examined externally as to dimensions, color, and other Small and Large 
peculiarities worthy of mention, are removed together, their Intestines 
mesenteric attachments being severed with a knife close to the 
bowels, which are then opened with a pair of scissors at the place where the mesen- 
tery was attached. During these incisions the contents of the several parts are 
observed and described. Next the intestines are cleansed and the condition of the 
individual portions, especially of the small intestine, is inspected with special regard 
to the Peyer's patches, the solitary follicles, the villi, and the intestinal folds. At 
least in every case of inflammation of the peritoneum the appendix is to be carefully 
examined. 

§ 22. In those cases in which poisoning is suspected the internal 
examination is to begin with the abdominal cavity. Before any- Cases of Poisoning 
thing else is done the external appearance of the upper abdominal 
viscera, their situation and extent, the filling of their vessels, and the presence of 
any odor are to be determined. In regard to the vessels, here as in other important 
organs, we are to ascertain whether we are dealing with arteries or veins, whether 
the smaller ramifications or both the main trunks and their branches are filled to a 
given degree, and whether the extent of the vascular thinning is considerable or 
otherwise. Then to the portion of the oesophagus just above its entrance into the 
stomach and to the duodenum just below the entrance of the gall-duct double liga- 
tures are to be applied and both parts incised between them. Next the stomach with 
the duodenum attached is carefully removed from the body and opened in the 
manner described in \ 21. The contents are immediately examined as to their 
amount, consistency, color, composition, reaction, and odor, and placed in a clean 
porcelain or glass vessel. Then the mucosa is washed and its thickness, color, 
surface, and condition are determined, the state of the blood-vessels and the struc- 
ture of the mucous membrane being particularly noted and each individual portion 
separately described. Of especial importance is it to ascertain whether the blood 
which is present lies within the vessels or is exuded therefrom, whether it is fresh 
or changed by decomposition or by digestion, and whether in these conditions the 
neighboring tissues are permeated therewith. If such imbibition has occurred, its 
location is to be determined, also whether upon the surface or in the tissue, whether 



344 POST-MORTEM EXAMINATIONS 

it is coagulated or not, etc. Finally it is of especial importance to decide, in the 
inspection of the surface, whether loss of substance, erosions, and ulcers are present. 
The question whether these changes might not have resulted from natural processes 
of decomposition after death, especially from the action of the fermentative juices 
of the stomach, is always to be considered. After the completion of this examina- 
tion, the stomach and duodenum are to be placed in the same vessel with the gastric 
contents (see above) and given to the magistrate for further investigation. An 
anatomical examination having been made of the oesophagus, it is tied high up in 
the neck, severed above the ligature, and placed in the same vessel. In those cases 
in which but a small amount of stomach contents is present the contents of the 
jejunum are also to be preserved. Finally other substances and portions of organs, 
as blood, urine, pieces of the liver and of the kidney, etc., are to be removed from 
the body and given to the magistrate for further examination. The urine is to be 
placed in a separate vessel, and the blood is to be preserved separately only in those 
cases where spectroscopic examination might disclose facts of interest. All of the 
remaining portions are to be placed together in a single receptacle. Each of these 
vessels is closed, sealed, and labelled. In every case where the macroscopical ex- 
amination shows special alteration and swelling of the mucous membrane of the 
stomach, a microscopical examination thereof is to be made as soon as possible, 
especial attention being given to the condition of the peptic glands. Whenever 
suspicious bodies are found in the stomach contents, as portions of leaves or other 
parts of plants, remnants of animal food, etc., these also are to be viewed with a 
microscope. Where trichinosis is suspected, not only a microscopical examination 
of the contents of the stomach and of the upper portion of the small intestine is to 
be made, but portions of muscular tissue from the diaphragm, the neck, and the 
thorax are also to be laid aside for future study. 

§ 23. In postmortems on the new-born, besides the points pre- 
The New-born; viously given, there are to be determined, first of all, the data 

Determination of the n w ^ j c h t h e maturity and the intra-uterine developmental 

Maturity and Period . . , , 

of Intra-uterine period of the child depend, .bor these purposes consider the 

Gestation length and weight of the body, condition of the general coverings 

and of the umbilical cord, length and appearance of the hair of 
the head, size of the fontanels, longitudinal, transverse, and diagonal measurements 
of the head, appearance of the eyes (pupillary membrane), condition of the nasal 
and auricular cartilage, length and characteristics of the nails, transverse diameter 
of the shoulders and hips ; in boys the situation of the testicles and the appearance 
of the scrotum, and in girls any peculiarities of the external genitalia. It still 
remains to be noted whether there be present, and if so to what extent, an ossifying 
centre in the inferior epiphysis of the femur. To determine this the patella is 
removed through a horizontal incision made just below it while the knee-joint is 
strongly flexed, and thin transverse sections are made continuously through the 
cartilage until the greatest transverse diameters of any centres of ossification which 
may there be present are found, which are then to be measured in millimetres. 
When from an examination of the offspring it seems to have been born before the 
thirtieth week, the postmortem may be discontinued unless a special request is given 
by the magistrate for its completion. 

\ 24. If it be determined that the child was born after the thir- 
The Determination feft*. week, the following data must be obtained in order to 
the Child has decide whether it breathed during or after birth. For this pur- 

breathed P os e the respiratory tests are to be applied in the following order : 

(a) Immediately after the opening of the abdominal cavity the 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 345 

condition of the diaphragm in relation to the corresponding ribs is to be determined. 
Hence in every case of examination of the new-born the abdominal cavity is to be 
opened first and afterwards the thoracic and cranial cavities. 1 (b) Before opening 
the thoracic cavity the trachea is to be once ligatured above the sternum, (c) The 
thoracic cavity is next to be opened and the extent and the degree of the over- 
hanging portions of the lungs, the latter especially in regard to the pericardium, 
determined both as to the color and as to consistency, (d) The pericardium is to 
be incised and both its condition and the external appearance of the heart are to be 
described, (e) The individual cavities of the heart must be laid open, their contents 
noted, and other appearances determined, (f) The larynx and the portion of the 
trachea above the ligature are to be slit, and their contents as well as the appearance 
of their walls determined, (g) The trachea is to be cut through above the ligature 
and removed in connection with the other organs of the thorax, (h) After the 
removal of the thymus gland and the heart, the lungs are to be tested as to whether 
or not they float in a large vessel filled with pure cold water, (i) The lower por- 
tion of the bronchus and its branches are to be opened and their contents specially 
examined. (/) Incisions are to be made into both lungs, the presence or absence of 
crepitation being carefully noted as well as the amount and appearance of any blood 
which may exude under slight pressure upon the cut surfaces, (k) The lungs are 
also to be incised under water in order to determine if any air-bubbles arise from 
the cut surfaces. (/) The lobes of both lungs are next to be cut apart, each lobe 
subdivided, and every separate portion tested as to its sinking or floating in water, 
(m) The oesophagus is to be opened and its condition ascertained, (n) Finally, in 
those cases where it is suspected that the pulmonary tissues may have been filled 
with the products of disease (hepatization) or with foreign bodies (vernix caseosa 
and meconium), so as not to permit of the entrance of air, the same are to be 
examined microscopically. 

\ 25. Lastly, it is the duty of the obducents to examine all organs 

, . , ... ... , Further 

not mentioned in these regulations in case injuries or other Examinations 

abnormalities are discovered. 

§ 26. The district surgeon, with the second physician acting as 

. ,• , , ,. , \ 1 Closure of the Body 

a consultant, is required, after the ending of the autopsy and as 
far as possible the removal of waste, to undertake the proper closure of those cavi- 
ties of the body which have been opened. 



III. THE DRAWING UP OF THE PROTOCOL OF THE POSTMORTEM 
AND THE FINAL REPORT OF THE SAME. 

\ 27. A post-mortem protocol is to be made by the magistrate, 
at the time and place of performing the autopsy, concerning all Protocol 
matters relating thereto. The medical officer must, therefore, 
be careful that the technical findings which have been determined at the examination 
are faithfully recorded in the protocol. In order to accomplish this, it is recom- 
mended to the magistrate that the description and findings of each individual organ 
be written down before another part is examined. 

1 But in no case shall section of the organs of the abdominal cavity be undertaken before the opening 
and examination of those of the thorax. 



346 



POST-MORTEM EXAMINATIONS 



£ 28. The technical findings given in the post-mortem protocol 
Arrangement and by the medical officer must be stated clearly, definitely, and in 
Form of the Protocol such a manner as to be understood by one who is not a physician ; 

for this purpose the use of foreign expressions is to be avoided 
except where these may be needed to make clear the description of the findings. 
Both chief divisions, the external and internal examinations, are to be designated 
with capital letters (A and B). The findings for the openings in the cavities are 
to be given, in the order in which they were examined, with Roman numerals (I., 
II.) ; but the organs in the thorax and abdominal cavity are to be entered under a 
single number. The descriptions of the organs of the thorax and abdominal cavity, 
named in § 18, are to be designated by the letters a and b. The results of the 
examination of each individual part are to be designated with Arabic numerals, 
such numbers running consecutively from the beginning to the end of the protocol. 
The record of the examination must be given in the protocol with special reference 
to the actual observations, and not in the form of mere statements, — as, for example, 
inflamed, gangrenous, healthy, normal, wound, ulcer, and the like. The obducents 
have the option, however, in those cases in which it seems necessary for clearness, 
to add such observations, inclosed in parentheses. In every case a note must be 
made of the blood contents of each important part, and a short description thereof 
must be given, and not simply a name, — as considerable, moderate, middling amount, 
much reddened, rich in blood, poor in blood. Before any part is incised its size, 
form, color, and consistency are to be noted, in the order here named. 

'$ 29. At the close of the postmortem the obducents are to give 
Provisional Opinion in the protocol their provisional opinion of the case, without 

stating their reasons therefor. If anything be known by means of 
Vv'hich the diagnosis is influenced, in the way of previous history or the like, this 
must be briefly noted. Should the magistrate ask any special questions, the answers 
should be distinctly entered in the protocol, with the statement that they are given 
at his request. In every case the opinion as to the cause of death is to be stated, 
first with special reference to the facts bearing on the objective findings and then 
as to the question of criminal motive. If the cause of death is not determined, this 
fact must be recorded. It is never sufficient to say that death resulted from 
internal causes or from disease. The latter, whatever it is, must be specifically 
named. Special mention is to be made, with the reason therefor, in cases where 
further technical examinations are needed or where doubtful conditions exist. 

\ 30. Should injuries be found on the body which were presuma- 
Supplemental ^j y ^ cause f death, and if suspicion be aroused that a specially 

Observations on ,. , . , . , , , . n . J , .... , 

Instruments discovered instrument might have inflicted such injuries, the 

obducents, at the request of the magistrate, are obliged to investi- 
gate and to express an opinion as to which and what injuries might have been 
caused by the instrument, and what conclusions from the situation and appearance 
of the wound are to be drawn as to the manner in which the one performing the 
act might have committed the deed, and also as to the strength with which it was 
performed. When definite weapons are not found, the obducents, as far as it is 
possible from the conditions present, are to give their opinion as to how the injuries 
were caused and especially as to what instruments might possibly have been used. 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 



347 



g 31. If the obducents be requested to present a report, this should 
give, without useless details, a condensed but exact review of Post-mortem Report 
the case, with the conclusion reached by them and the facts on 
which it is based. So much of the post-mortem protocol as they think necessary 
for the explanation of the case is to be given verbatim, with the number of the 
protocol. Any change made therein must be expressly stated. The style of the post- 
mortem report must be plain and concise, and the proof which led to the formation 
of the opinion therein expressed so set forth as to be understood by and convincing 
to one not a physician ; for this purpose, the obducents are to use, as far as possible, 
German expressions and ordinarily accepted meanings. Especial attention to literary 
sources of knowledge is, as a rule, to be avoided. When as medical experts the 
obducents are asked certain questions by the magistrate, these are to be answered 
fully but as concisely as possible, or, if this cannot be done, the reasons therefor 
are to be given. 

Both obducents must sign their report, which must also bear the official seal of 
the district physician if he has taken part in the autopsy. When such a post-mortem 
account is requested, it must be delivered by the obducents within four weeks at 
the latest. 



CHAPTER XXIX 

USUAL CAUSES OF DEATH; THEIR NOMENCLATURE, COMPLICATIONS, 

AND SYNONYMS 

As morbidity and mortuary statistics are intimately associated 
the one with the other, uniformity in their nomenclature throughout 
the world is greatly to be desired. At the Eighth International Con- 
gress of Hygiene and Demography, held in Paris, August 18 to 21, 
1900, a modification of the old Bertillon classification was adopted and 
called the " International System of Nomenclature of Diseases and 
Causes of Death." 1 It is here added complete as to its essential parts 
and but slightly altered in a few minor particulars. 

I. GENERAL DISEASES. 

1. Typhoid Fever (Abdominal Typhus). Include: Dothienenteritis ; mucous, 

continued, enteric, ataxic, or adynamic fever; abdominal typhus. — Do not 
include: Adynamia (179) ; ataxo-adynamia (179). — Frequent complications: 
Pneumonia; pulmonary congestion; intestinal perforation ; peritonitis; in- 
testinal hemorrhage; sloughing; albuminuria. 

2. Exanthematous Typhus. 2 Include : Petechial fever; petechial typhus. — Do 

not include: Abdominal typhus. 

3. Recurrent Fever. Include: Relapsing fever; recurrent typhus. 

4. Intermittent Fever and Malarial Cachexia. Include: Paludal fever; per- 

nicious fever ; accesso pernicioso ; remittent fever ; malaria. 

4a. Malarial Cachexia. Include: Paludism ; pernicious cachexia; paludal 
anaemia. 

5. Variola. Include: Smallpox, varioloid. — Do not include: Varicella (19). — 

Frequent complications: Meningitis; endocarditis; suppuration; albumin- 
uria. 

6. Measles. Include: Eruption of measles. — Do not include: Rubeola (19). — 

Frequent complications: Bronchitis; bronchopneumonia. 

7. Scarlatina. Include: Puerperal scarlatina; scarlatinous angina. — Frequent 

complications: Albuminuria; eclampsia; oedema of the glottis; hemor- 
rhage ; endocarditis ; pericarditis ; paralysis ; convulsions. 

8. Whooping Cough. Frequent complications: Bronchitis; convulsions. 

9. Diphtheria and Croup. Include: Diphtheritic, buffy, pseudomembranous, 

infectious, malignant, or toxic angina. Diphtheria under all its forms, espe- 
cially diphtheria of wounds, cutaneous diphtheria; conjunctival diphtheria; 

1 Supplement to Public Health Reports, vol. xv., No. 49. Translated by Passed Assistant Surgeon 
H. D. Geddings. 

2 The word "typhus," without qualification, will be taken in the sense which is usual to it in each 
country, — viz., in the sense of " abdominal typhus" in German-speaking countries, or as " exanthematous 
typhus" in French-speaking ones. 

348 



USUAL CAUSES OF DEATH ?>A9 

buccal diphtheria. Pseudomembranous bronchitis ; pseudomembranous lar- 
yngitis ; malignant laryngitis; diphtheritic paralysis. — Do not include: 
Stridulous croup (88) ; spasmodic croup (88). — Frequent complications: 
Pneumonia ; albuminuria ; paralysis. 
9a. Diphtheria. 

10. Grippe. Include: Influenza; grippe pneumonia ; grippe bronchitis, and grippe 

bronchopneumonia. 

11. Sweating or Miliary Fever. 

12. Asiatic Cholera. Include: Indian cholera; cholera (without qualification) ; 

epidemic cholera. 

13. Cholera Nostras. 1 Include: Sporadic cholera; cholerine; choleriform en- 

teritis or diarrhoea. — Do not include: Cholera infantum; antimony cholera 
(175) ; hernial cholera (108). 

14. Dysentery. Include: Choleriform dysentery; Chinese dysentery; dysentery 

of tropical countries. 
14a. Epidemic Dysentery. 

15. Pest (Plague or Bubonic Plague). 

16. Yellow Fever. Include: Vomito negro; fiebre amarilla. 

17. Leprosy. Include: Elephantiasis Graecorum. — Do not include: Elephantiasis 

Arabum (143d) ; Morvan's disease (63) ; syringomyelias (6s). 

18. Erysipelas. Include: All surgical erysipelas or medical erysipelas, without 

regard to seat. — Do not include: Gangrenous or phlegmonous erysipelas 
(144) ; erysipelatous phlegmon (144). 

19. Other Epidemic Affections. 2 Include: Mumps; rubeola; acrodynia; vari- 

cella ; beriberi ; and any other epidemic affections which may not be in- 
cluded in this nomenclature. — Do not include: Epidemic dysentery (14a) ; 
epidemic cerebrospinal meningitis. 

20. Purulent and Septicemic Infection. 3 Include: Pyohaemia; purulent ab- 

sorption ; putrid absorption ; putrid infection ; putrid fever ; anatomical 
wounds; streptococchaemia. — Do not include: Puerperal septicaemia (137); 
infectious fever (55). 

21. Glanders and Farcy. 

22. Malignant Pustule and Charbon (Anthrax). 

23. Rabies. Include: Hydrophobia. — Do not include: Sitiophobia (68). 

24. Actinomycosis, Trichinosis, etc. Include: Dystoma hepaticum; cysticerci. 

— Do not include: Cyst or hydatid tumor of the liver (in) or of the lungs 
(99) ; intestinal parasites (107). 

25. Pellagra. 

26. Tubercle of the Larynx. Include: Tuberculous laryngitis; laryngeal 

phthisis. 

27. Tubercle of the Lungs.* Include: Pulmonary tuberculosis; pulmonary 

phthisis; phthisis (without qualification) ; phymia ; phymatosis ; pneumo- 
nophyma ; acute, galloping, or miliary phthisis or tuberculosis ; granulia ; 
pulmonary cavities ; consumption ; caseous pneumonia ; tuberculous, bacil- 



1 The word " cholera morbus" will be taken in its ordinary signification in each country, as in the 
sense of " cholera nostras" in North America, and as " Asiatic cholera" in France and in other countries. 

2 In cases where epidemics arise, it will be necessary here to adopt a special provisional title. 

3 When an adult female is returned as having been stricken with " septicaemia," send the report back 
in order that the physician may state whether or not the disease was puerperal. 

4 See observation on No. 93, relative to " apical pneumonia." 



350 POST-MORTEM EXAMINATIONS 

lary, specific, granular, neoplastic, or heteroplastic bronchitis or pneumonia; 
bacillosis; tuberculous pleurisy; tuberculous haemoptysis; tuberculosis 
(without qualification). — Do not include: Haemoptysis (without qualifica- 
tion) (99) ; pulmonary hemorrhage (99) ; bronchorrhagia (without qualifi- 
cation) (99) ; apical pneumonia (93) ; laryngeal phthisis (26) ; pulmonary 
anthracosis (99). — Frequent complications: Hemorrhage; pneumonia; pleu- 
risy; incontrollable diarrhoea. 

28. Tubercle of the Meninges. Include: Meningeal tuberculosis; tuberculous 

meningitis ; granular, miliary, caseous, bacillary, specific, neoplastic or heter- 
oplastic meningitis. — Do not include: Meningitis (without qualification), 
even for children of tender age. 

29. Abdominal Tubercle. Include: Tuberculous, granular, bacillary, or specific 

peritonitis ; peritoneal tuberculosis ; tuberculous enteritis. 

30. Pott's Disease. Include: Vertebral caries ; vertebral disease; vertebral poly- 

arthritis. — Frequent complications: Cold abscess, or abscess by congestion. 

31. Cold Abscess and Abscess by Congestion. Include:- Ossifluent abscess. 

32. White Swelling. Include: Fungous growths of joints; coxalgia; scapu- 

lalgia. 
Z2,. Other Tuberculous Affections. Include: Tuberculosis of the skin; tuber- 
culous nephritis ; lupus ; esthiomene ; bacillary abscess ; tuberculous ulcer ; 
osseous tuberculosis. — Do not include: Pott's disease (30). 

34. Generalized Tuberculosis. Include: Tuberculosis showing itself simulta- 

neously in any two or more organs. 

35. Scrofula. Include: Lymphatism; scrofulides. — Do not include: Blepharitis; 

or conjunctivitis, or scrofulous keratitis, or lymphatic keratitis (75). 

36. Syphilis. Of which are recognized: (1) Primary, (2) secondary, (3) ter- 

tiary, (4) hereditary. These divisions are intended for mortuary statistics 
alone. Include: (1) Indurated or infecting chancre; chancre of the mouth 
or face; primary accident or infection; (2) Secondary manifestations — 
mucous plaques ; syphilitic amygdalitis ; angina or laryngitis ; (3) Tertiary 
manifestations — specific manifestations ; gummata ; ulcerations ; exostoses, 
etc. Osteocopic pains ; all these diseases to be specified as " syphilitic." — 
Do not include: Soft, simple, or phagedenic chancre (36a). 
36a. Soft Chancre. Include: Chancroid; chancrelle; simple chancre; phagedenic 
chancre or bubo ; bubo of soft chancre ; venereal, virulent, or absorption 
buboes. — Do not include: Infecting or syphilitic chancre or bubo (36, 1) ; 
chancre of the mouth (36, 1) ; scrofulous bubo (35) ; suppurating bubo 
(144) ; plague bubo (15) ; bubo without qualification (144). (Morbidity 
statistics only.) 

37. Blennorrhagia of the Adult. Include: Blennorrhoea ; gonorrhoea; ardor 

urinae ; urethritis ; military drop ; balanitis ; balanorrhagia ; balanopos- 
thitis, vaginitis ; gonorrhoeal cystitis, orchitis, buboes, arthritis, rheumatism, 
or conjunctivitis of the adult; or gonorrhoeal or blennorrhagic ophthalmia of 
-the adult. — Do not include: Vaginismus (132); vaginalitis (126). — Fre- 
quent complications: Bubo; adenitis; cystitis ; orchitis. 

38. Gonorrheal Affections of the Child. 1 Include: Blennorrhagic or gonor- 

rhoeal conjunctivitis of the child (under five years of age) ; gonorrhoeal 
vulvitis (of the child under five years). 



This title takes no account of children over five years of age. 



USUAL CAUSES OF DEATH 35 1 

39. Cancer and other Malignant Tumors of the Buccal Cavity. Include: 

Cancer of the month or lips, or of the tongue, or the roof of the mouth, or 
the velum of the palate ; cancer of the maxilla ; epithelioma, or carcinoma., 
or cancroid of these organs ; smokers' cancer. 

40. Cancer and other Malignant Tumors of the Stomach and Liver. 1 In- 

clude: Cancer of the oesophagus; cancer of the cardia; cancer of the py- 
lorus ; carcinoma or scirrhus, or colloid or encephaloid tumor of these 
organs; gastrocarcinoma ; tumor of the stomach. — Do not include: Haema- 
temesis (104). 

41. Cancer and other Malignant Tumors of the Peritoneum, Intestines, and 

Rectum. Include: Cancer of the colon ; cancer of the anus ; carcinoma, or 
scirrhus, or encephaloid, or cancroid, or epithelioma of these organs. 

42. Cancer and other Malignant Tumors of the Female Genital Organs. 

Include: Cancer of the uterus; cancer of the womb; cancer of the vagina; 
cancer of the vulva ; carcinoma, or encephaloid, or colloid tumor, or hetero- 
morphous or neoplastic growth, or cancroid, or sarcoma, or epithelioma of 
these organs. 

43. Cancer and other Malignant Tumors of the Breast. Include: Carcinoma, 

or scirrhus, or encephaloid, or heteromorphous or neoplastic growth, or can- 
croid, or epithelioma of the breast or nipple. 

44. Cancer and other Malignant Tumors of the Skin. Include: Cancroid 

(without qualification) ; epithelioma or epitheliomatous tumor (without 
qualification) ; cancer of the ear, of the face, or cervicofacial ; " noli me 
tangere." — Do not include: Esthiomene (33) ; lupus (33). 

45. Cancer and other Malignant Tumors of other Organs, and of Organs not 

classified. Include: Abdominal cancer; pelvic cancer; cancer of the lung, 
of the kidney, of the bladder, and of the prostate ; cancerous goitre ; thyro- 
sarcoma ; sarcohydrocele ; cancer of the bone ; osteosarcoma ; cancerous or 
sarcomatous tumor of the neck ; carcinoma, or scirrhus, or encephaloid, or 
cancerous ulcer, or malignant tumor, or sarcoma, or malignant fungus of 
these organs, or of other organs not specified. — Do not include: Cancer of 
the oesophagus (40) ; cancer of the anus (41) ; cancer of the ovary, vagina, 
or vulva (42). 

46. Other Tumors (Tumors of the Female Genital Organs excepted). Include: 

Tumor (without qualification); abdominal tumor; intestinal tumor; vas- 
cular or erectile tumor ; angioma ; lymphoma ; lymphadenoma ; lymphato- 
cele ; adenoma ; chondroma ; osteoma ; myoma ; lipoma ; wen ; grub ; 
sebaceous tumor; cystoma. — Do not include: Cancer and its synonyms (40- 
45) ; tumor of the stomach (40) ; stercoraceous tumor (108) ; tumor of the 
uterus (129) ; hydatid tumor (in) ; cyst of the ovary (131) ; aneurismal 
tumor (81) ; varicose tumor (83) ; polyp of the ear (76) ; polyp of the 
nasal or nasopharyngeal fossae (87) ; uterine polyp (129). 

47. Acute Articular Rheumatism. Include: Rheumatic arthritis; rheumatic 

meningitis; abdominal or cerebral rheumatism; rheumatic vertigo; rheu- 
matic endocarditis, pericarditis, pleurisy, or peritonitis. — Do not include: 
Organic diseases of rheumatic origin (79, etc.) ; rheumatic iritis (75) ; 
arthritis deformans (48) ; gonorrhceal rheumatism (37). 

1 In countries where the words "organic lesion of the stomach" always signify "cancer of the 
stomach" classify these diagnoses under No. 40. In countries where, on the contrary, this is not always 
so, classify them under No. 104. 



352 POST-MORTEM EXAMINATIONS 

48. Chronic Rheumatism and Gout. Include: Arthritis deformans. 

49. Scorbutus. Include: Werlhoff's disease. 

50. Diabetes. Include: Glycosuria. — Frequent complications: Pneumonia; an- 

thrax ; gangrene ; cerebral hemorrhage and cerebral softening ; tubercu- 
losis. 

51. Exophthalmic Goitre. Include: Exophthalmia ; Basedow's disease; Graves's 

disease; exophthalmic cachexia. — Frequent complications: Hypertrophy of 
the heart ; cachexia. 

52. Addison's Disease. Frequent complications: Cachexia; ascites. 

53. Leukaemia. Include: Adenoleukaemia ; leucocythaemia ; Hodgkin's disease; 

pseudoleukemia. — Frequent complications: Hemorrhage; ascites; apoplexy; 
cachexia. 

54. Anaemia; Chlorosis. Include: Pernicious anaemia. — Do not include: Cere- 

bral anaemia (74b). 

55. Other General Diseases. Include: Autointoxication; infectious fever ; viru- 

lent disease (without explanation); visceral steatosis; acromegalia; amy- 
loid or generalized fatty degeneration. 

56. Alcoholism, Acute or Chronic. Include: Drunkenness; ethylism; alcoholic 

intoxication ; alcoholic delirium ; alcoholic dementia ; delirium tremens ; 
absinthism; absinthaemia ; dipsomania. — Do not include: Alcoholic cirrho- 
sis (112) ; general alcoholic paralysis (67) ; atheroma (81) ; or any other 
disease attributable to alcohol; intoxication amblyopia (75). 

57. Saturnism. Include: Saturnine colic; lead colic; painters' colic; lead en- 

cephalopathia ; lead paralysis; chronic lead poisoning; all conditions char- 
acterized as '' saturnine." 

58. Other Trade or Occupation Intoxications. Include: Mercurial (hydrar- 

gyrism) ; phosphorus, arsenical, or other intoxication, when special mention 
by the physician makes it clear that the intoxication is the result of a trade. 
Failing in this specific declaration, it should be classed in one of the condi- 
tions under No. 59. 

59. Other Chronic Poisonings. 1 Include: Morphinism; cocainism; chronic er- 

gotism. — Do not include: Amblyopia by intoxication (75). 



II. DISEASES OF THE NERVOUS SYSTEM AND OF THE ORGANS 

OF SPECIAL SENSE. 

60 Encephalitis. Include: Cerebral fever. 

61. Simple Meningitis. Include: Meningitis (without qualification) ; meningo- 

encephalitis ; pachymeningitis. 
61a. Epidemic Cerebrospinal Meningitis. Do not include: Tuberculous menin- 
gitis (or other synonym) (28) ; rheumatic meningitis (47). 

62. Progressive Locomotor Ataxia. Include: Duchenne's disease. 

63. Other Diseases of the Spinal Cord. Include: Disease of the cord; sclerosis 

in plaques; symmetrical sclerosis; lateral sclerosis; sclerosis (without 
qualification); Charcot's disease ; Morvan's disease; syringomyelitis ; spas- 
modic tabes dorsalis ; hemorrhage into the spinal cord ; haematomyelitis ; 
haematorrhachia ; myelitis ; medullary congestion ; affections of the bulb ; 
bulbar paralysis ; spinal paralysis ; paralysis agitans ; trembling paralysis ; 



Note the observation under the preceding title. 



USUAL CAUSES OF DEATH 353 

ascending paralysis; essential paralysis of infancy; fatty or amyloid degen- 
eration of the cord ; Parkinson's disease ; Friedreich's disease ; medullary 
compression or compression of the cord ; progressive muscular atrophy ; 
fatty degeneration of muscles ; atrophic muscular paralysis ; amyotrophia ; 
amyotrophic paralysis ; atrophic paralysis ; pseudohypertrophic paralysis. 

64. Cerebral Congestion and Hemorrhage. Include: Apoplexy; cerebral apo- 

plexy ; meningeal apoplexy ; serous apoplexy ; cerebral atheroma ; cedema 
of the brain ; cerebral effusion ; cerebellar hemorrhage ; meningeal hemor- 
rhage; cataplexia ; apoplectic dementia. — Frequent complications: Hemi- 
plegia ; paralysis. 

65. Cerebral Softening. Do not include: Senile dementia. — Frequent complica- 

tions: Hemiplegia; paralysis; pulmonary congestion. 

66. Paralysis without Specified Cause. Include: Paralysis (without qualifica- 

tion) ; hemiplegia; facial paralysis; generalized paralysis (not to be con- 
founded with general paralysis). — Do not include: Diphtheritic paralysis 
(9) ; atrophic muscular paralysis (63) ; general paralysis (67) ; paralytic 
cachexia or marasmus (67) ; paralytic dementia or idiocy (67) ; shaking or 
trembling paralysis (6s) ; bulbar paralysis (63) ; ascending paralysis (63) ; 
essential paralysis of infancy (63) ; labioglossolaryngeal paralysis (74b) ; 
paralysis of the velum palati (101) ; paralysis of the muscles of the eye (53). 

67. General Paralysis. Include: Paralytic lunacy; paralytic dementia; para- 

lytic cachexia ; paralytic marasmus ; diffuse meningoencephalitis ; diffuse 
peri-encephalitis. — Do not include: Generalized paralysis (66). 

68. Other Forms of Mental Alienation. Include: Dementia; lunacy; un- 

soundness of mind ; hallucinations ; mania ; megalomania ; monomania ; 
delusions of persecution ; melancholia ; lypemania ; nostalgia ; spleen ; noso- 
phobia ; necrophobia ; sitiophobia ; lycanthropy ; homesickness ; andro- 
mania; nymphomania; priapism; satyriasis; mental disease. — Do not in- 
clude: Alcoholic dementia or delirium (56) ; delirium tremens (56) ; de- 
lirium (179) ; uraemic delirium (120) ; apoplectic dementia (64) ; paralytic 
dementia (67) ; choreic dementia (73) ; senile dementia (154) ; hysteria 
(74a). 

69. Epilepsy. Include: " Haut mal;" disease of Hercules. — Do not include: Epi- 

leptiform convulsions (70). 

70. Eclampsia (Non-puerperal). 1 Include: Epileptiform convulsions (of adults). 

— Do not include: Scarlatinous eclampsia (7) ; ursemic eclampsia (120) ; 
eclampsia of young infants (71). 

71. Convulsions of Children. 2 Include: Eclampsia of young children; con- 

tractures of children. — Do not include : Trismus nascentium. 

72. Tetanus. Include: Opisthotonos; emprosthotonos ; pleurosthotonos ; tris- 

mus nascentium. 

73. Chorea. Include: Choreic dementia ; Bergeron's disease. 

74. Hysteria. Include: Hysterical anorexia; hysterical colic; all diseases classi- 

fied as "hysterical." (Morbidity statistics alone.) 
74a. Neuralgia. Include: Tic douloureux; sciatica. (Morbidity statistics alone.) 
74b. Other Diseases of the Nervous System. Include: Cerebral compression, 

cerebral tumor ; acquired hydrocephalus ; neuroma; encephalopathia (with- 

1 When a female of child-bearing age is designated as having been stricken with " eclampsia," return 
the report to have the physician state whether or not the disease was puerperal. 

2 This title only applies to children under five years of age. 

23 



354 POST-MORTEM EXAMINATIONS 

out qualification) ; idiocy; imbecility; cretinism; gatism ( ?) ; amnesia; 
paramnesia; loss of speech; aphasia; nervous or cerebral accidents; cere- 
bral anaemia ; neurosis ; tic ; convulsive tic ; contracture ; anaesthesia ; neu- 
rasthenia; migraine; vertigo; somnambulism; catalepsy; boulimia; Lan- 
dry's disease ; symptomatic or Jacksonian epilepsy ; athetosis ; labioglosso- 
laryngeal paralysis ; amyloid or fatty degeneration of the nervous system. — 
Do not include: Senile dementia, imbecility or gatism (?) (154) ; syringo- 
myelias (63) ; myxcedema (89) ; congenital or undescribed hydrocephalus 
(150). 

75. Diseases of the Eye and its Adnexa. Include: Ophthalmia; foreign bodies ; 

conjunctivitis (not including diphtheritic conjunctivitis); xerophthalmia; 
xerosis; pterygion; Pinguecula; keratitis of every description; staphy- 
loma ; diseases of the cornea ; arcus senilis ; diseases of the sclerotic ; dis- 
eases of the iris; iritis; diseases of the choroid; choroiditis; iridocho- 
roiditis ; sclerochoroiditis ; glaucoma ; diseases of the retina ; retinitis ; 
optic neuritis ; amaurosis ; amblyopia ; amblyopia by intoxication ; hemio- 
pia; hemeralopia; nyctalopia; diseases of the lens; cataract; aphacia; 
parasites of the eye ; ophthalmozoa ; coloboma ; strabismus ; strabotomy ; 
paralysis of the muscles of the eye ; nystagmus ; styes ; chalazion ; blephar- 
itis; blepharoconjunctivitis; scrofulous blepharitis ; blepharophimosis ; ble- 
pharoplastia ; ectropion ; entropion ; trichiasis ; dacryoadenitis ; diseases of 
the lachrymal gland and lachrymal sac ; dacryocystitis ; dacryolithiasis ; 
dacryoma; lachrymal fistula; diseases and tumors of the orbit (cancer ex- 
cepted). — Do not include: Diphtheritic conjunctivitis (9) ; cancer of the eye 
(45) > ocular tuberculosis (33) ; exophthalmic goitre (51) ; exophthalmia 
(51). 

75a. Follicular Conjunctivitis. (Morbidity statistics alone.) 

75b. Trachoma. (Morbidity statistics alone.) 

76. Diseases of the Ear. Include: Otitis; otorrhcea ; catarrh of the ear ; hydro- 

titis ; foreign body in the auditory canal ; obstruction of the auditory canal ; 
polyp of the ear ; inflammation of the tympanum ; " vertigo ab aure laeso ;" 
Meniere's disease, or vertigo; caries of the labyrinth (?) ; deafness; deaf- 
mutism. — Do not include: Mumps. 



III. DISEASES OF THE CIRCULATORY APPARATUS. 

77. Pericarditis. Include: Cardiopericarditis ; hydropericarditis ; hydropneumo- 

pericarditis ; pericardial adhesions. — Do not include: Rheumatic pericarditis 
(47) ; endopericarditis (78) ; pleuropericarditis (94) ; pneumopericarditis 

(93). 

78. Acute Endocarditis. Include: Endocarditis (without qualification) ; myo- 

carditis, acute or without qualification; endopericarditis. — Do not include: 
Rheumatic endocarditis, or the other cardiac accidents which may supervene 
in the course of an attack of rheumatism. 

79. Organic Diseases of the Heart. Include: Aortic, mitral, tricuspid, or car- 

diac affection or lesion; cardiac or valvular insufficiency or stenosis of the 
valves of the heart ; cardiac cachexia ; hypertrophy of the heart ; dilatation 
of the heart ; cardiectasis ; steatosis of the heart ; degeneration of the heart ; 
cardiopathy ; cardiosclerosis ; cardiovascular sclerosis ; cardiomalacia ; car- 
diostenosis; labored heart; tachycardia; rupture of the heart; cardior- 



USUAL CAUSES OF DEATH 



355 



rhexia ; cardiac palpitations; asystole; cardiac asthma. — Do not include: 
Cardiac accidents (undetermined) (86) ; persistence or patency of the fora- 
men of Botallo (150). — Frequent complications: Dropsy; bronchitis and 
pneumonia ; albuminuria ; embolism ; thrombosis. 

80. Angina Pectoris. Include: Cardialgia ; sternalgia; neuralgia of the heart. 

81. Affections of the Arteries, Atheroma, Aneurism, etc. Include: Arteritis; 

fatty degeneration of arteries ; arteriosclerosis ; atheroma of arteries ; arte- 
riectasis ; aortic ectasis ; Hodgson's disease ; atresia of the pulmonary ar- 
tery ; aortitis; aneurismal tumor.— Do not include: Aortic affection (79). 

82. Thrombosis and Embolism. Include: Thrombosis (non-puerperal) ; phleg- 

masia alba dolens (non-puerperal). — Do not include: Embolism (puerperal) 
(140). 

83. Affections of Veins (Varices, Hemorrhoids, Phlebitis, etc.). Include: Pneu- 

mophlebitis; varicose ulcer; varicocele. — Do not include: Puerperal phle- 
bitis (137) ; vascular or erectile tumor (46) ; angioma (46). 

84. Affections of the Lymphatic System. Include: Angioleucitis ; adenopa- 

thia; lymphangeitis. — Do not include: Suppurative adenitis (144); adeno- 
phlegmon (144) ; leucaemic adenitis (53) ; lymphatism (36a) ; bubo (36a) ; 
adenoma (46) ; lymphoma (46) ; lymphadenoma (46). 

85. Hemorrhages. Include: Hemorrhage (without qualification) ; internal hem- 

orrhage ; haemophilia ; epistaxis ; stomatorrhagia ; cutaneous hemorrhage ; 
purpura haemorrhagica. — Do not include: Cerebral hemorrhage (64) ; cere- 
bellar hemorrhage (64) ; meningeal hemorrhage (64) ; pulmonary hemor- 
rhage (99) ; haemoptysis (99) ; haematemesis (104) ; intestinal hemorrhage 
(109) ; haematuria (121) ; uterine, hemorrhage (135 or 128, depending on 
whether it is or is not puerperal) ; metrorrhagia (128 or 135) ; umbilical 
hemorrhage (152) ; traumatic hemorrhage (166). 

86. Other Affections of the Circulatory Apparatus. Include: Cardiac acci- 

dents (undetermined); angiectasis; angiectopia; affections of the great 
vessels; permanently slow pulse. — Do not include: Vascular naevus (150). 

IV. DISEASES OF THE RESPIRATORY APPARATUS. 

87. Diseases of the Nasal Fossje. Include: Coryza; cold; polypus of the nasal 

or nasopharyngeal fossa; ozaena; abscess of the nasal fossa; adenoid vege- 
tations. — Do not include: Epistaxis (85) ; syphilitic coryza (36). 

88. Affections of the Larynx. Include: Acute, chronic, erysipelatous, cedema- 

tous, phlegmonous, or stridulous laryngitis ; aphonia ; loss of voice ; false 
croup ; spasmodic croup ; stridulous croup ; oedema of the glottis ; spasm of 
the glottis ; polypus of the larynx ; stricture of the larynx ; laryngotomy. — 
Do not include: Tuberculous laryngitis (26) ; laryngeal tuberculosis (26) ; 
croup (9) : diphtheritic laryngitis and its synonyms (8) ; foreign bodies in 
the larynx (176). 

89. Affections of the Thyroid Body. Include: Goitre; pulsating thyrocele; 

myxcedema ; pachydermic cachexia. 

90. Bronchitis, Acute. 1 Include: Capillary bronchitis; tracheitis; tracheobron- 

chitis; broncho-alveolitis. — Do not include: Bronchopneumonia (92); spe- 
cific bronchitis or other synonym of pulmonary tuberculosis (see No. 27) ; 
fetid bronchitis (96); summer bronchitis (99). 

1 See note on No. 91. 



356 POST-MORTEM EXAMINATIONS 

91. Bronchitis, Chronic. 1 Include: Mucous bronchitis (pituitous) ; catarrh 

(without qualification) ; bronchial, pituitous, pulmonary, or suffocating bron- 
chitis ; bronchorrhcea ; dilatation of the bronchi; bronchiectasis. — Do not 
include: Fetid bronchitis (96) ; tuberculous bronchitis (27). 

92. Bronchopneumonia. Include: Catarrhal pneumonia. — Do not include: Capil- 

lary bronchitis. 

93. Pneumonia. 2 Include: Croupous pneumonia; fluxion of the lung; pleuro- 

pneumonia ; pneumopleurisy ; splenopneumonia ; apical pneumonia ; peri- 
pneumonia; pneumopericarditis ; typhoid pneumonia. — Do not include: 
Caseous pneumonia (27) ; specific, bacillary, or any synonym of pulmonary 
tuberculosis (27) ; pulmonary congestion (95). 

94. Pleurisy. Include: Pleuropericarditis ; pleuritic or thoracic effusion; pneu- 

mothorax ; hydropneumothorax ; pyothorax ; pleural vomica ; pneumopyo- 
thorax ; hemothorax ; thoracentesis ; empyema ; pleural adhesions. — Do 
not include: Pleurodynia (99). 

95. Pulmonary Congestion and Pulmonary Apoplexy. Include: QEdema of the 

lungs. 

96. Gangrene of the Lung. Include: Fetid bronchitis. 

97. Asthma. Do not include: Cardiac asthma (79) ; suffocating catarrh (91) ; 

hay fever (99). 

98. Emphysema of the Lungs. Include: Emphysema (without qualification). — 

Do not include: Subcutaneous emphysema. 

99. Other Diseases of the Respiratory Apparatus (Phthisis excepted). In- 

clude : Tracheostenosis ; pleurodynia ; pneumopathy ; hydatids of the lung ; 
pulmonary calculus ; abscess of the lung ; pulmonary anthracosis ; inter- 
stitial pneumonia ; cirrhosis of the lung ; secondary sclerosis ; hay fever 

(summer bronchitis or catarrh). To be also included when their nature is 
not indicated: Organic lesion of the lung; pulmonary accidents; haemop- 
tysis ; spitting of blood ; pulmonary hemorrhage ; pneumorrhagia ; bron- 
chorrhagia; tracheotomy. — Do not include: Cancer of the lung (45). 



V. DISEASES OF THE DIGESTIVE APPARATUS. 

100. Affections of the Mouth and its Adnexa. Include: Diseases of the gums; 

epulis; gingivitis; ulorrhagia; glossitis; diseases of the tongue (except 
cancer); parotid tumor; parotiditis; salivary fistula; ranula; thrush; 
diseases of the teeth; odontalgia; dental caries; staphylitis ; staphylo- 
plasty; staphylorrhaphy. — Do not include: Cancer of the lips or tongue 
(39) ; chancre of the mouth (36a) ; noma (142) ; mumps (19) ; gangrene 
of the mouth (142) ; diseases of the palate (146 or 36) ; fracture of the 
maxilla (164) ; necrosis of the maxilla (146) ; paralysis of the velum 
palati (101). 

101. Affections of the Pharynx. Include: Angina or Ludwig's disease; anginas 

of all descriptions (except diphtheritic angina and its symptoms; see Diph- 
theria, No. 9); amygdalitis; quinsy; abscess of the fauces, throat, or 

1 Return to the physician the reports given in as " bronchitis," in order that he may specify acute or 
chronic. When the physician fails thus to answer, classify under No. 90 all reports of children under five 
years of age, and under No. 91 all reports of those of greater age. 

2 In countries where " apical pneumonia" is always synonymous with " phthisis," class this diagnosis 
under No. 27. In countries, on the contrary, where this is not constant, class under No. 93. 






USUAL CAUSES OF DEATH 357 

retropharynx ; paralysis of the velum palati ; elongation of the uvula ; 
pharyngitis. — Do not include: Angina pectoris (80) ; cardiac angina (80) ; 
scarlatinal angina (7). 

102. Affections of the CEsophagus. Include: Foreign bodies in the cesophagus; 

wound of the cesophagus; stricture of the cesophagus (except from can- 
cer) ; spasm of the cesophagus; cesophagotomy. — Do not include: Cancer 
of the cesophagus (40) ; stricture of the cesophagus, syphilitic (36). 

103. Ulcer of the Stomach. Include: Round ulcer. — Frequent complications: 

Haematemesis ; perforations of the stomach ; peritonitis. 

104. Other Affections of the Stomach (Cancer excepted). 1 Include: Dilata- 

tion of the stomach ; paresis of the stomach ; dyspepsia ; apepsia ; gas- 
tritis ; gastrohepatitis ; foreign body in the stomach ; gastrotomy ; perfora- 
tion of the stomach (non-traumatic); gastralgia; "vertigo a stomacho 
laeso ;" catarrh of the stomach ; indigestion. To be also included when 
their nature is not indicated : Gastrorrhagia ; hsematemesis ; gastric hemor- 
rhage. — Do not include: Gastro-enteritis (105 or 106, according to age). 

105. Diarrhcea and Enteritis (under two years). Include: Gastro-enteritis or 

gastrocolitis of children ; infantile enteritis ; cholera infantum ; athrepsia. 
This title only considers these ailments in children under two years. 
105a. Diarrhcea and Enteritis, Chronic Include: Athrepsia. 

106. Diarrhcea and Enteritis (two years and over). Include: Gastro-enteritis 

or gastrocolitis of adults ; enteritis of adults ; diarrhcea of adults ; lien- 
enteritis ; intestinal ulcerations ; colitis ; intestinal colic ; flatulent colic ; 
inflammatory colic. Do not include: Tuberculous enteritis. 

107. Intestinal Parasites. Include: Helminthse; oxyuri; taenia; solitary worm; 

ascaris lumbricoides ; trematodes ; trichocephalus ; ankylostomes ; colic 
from worms. 

108. Hernias and Intestinal Obstructions. Include: Internal strangulation; 

intestinal invagination ; stercoral tumors ; ileus ; intestinal occlusion ; volvu- 
lus ; hernial colic ; hernial gangrene. The following to be included when 
their nature is not specified : Merocele ; sarco-epiplocele ; sarco-epiplom- 
phalitis ; kelotomy ; herniotomy ; artificial anus ; stercoraceous vomiting. 
— Do not include: Laparotomy (without other qualification) (46). — Fre- 
quent complication: Peritonitis. 

109. Other Affections of the Intestines. Include: Paralysis or paresis of the 

intestine ; enteroptosis ; constipation ; stercoraemia ; intestinal calculi ; in- 
testinal perforation ; foreign bodies in the intestine or rectum ; rectitis. 
Include also the following diseases when their nature is not indicated, and 
these operations when their cause is not specified : Enterotomy ; artificial 
anus ; enterrhagia ; intestinal hemorrhage ; melaena ; prolapsus of the rec- 
tum; stricture of the rectum. — Do not include: Stercoral tumor (108); 
intestinal invagination and its synonyms (108); typhlitis (118); peri- 
typhlitis (118). 
109a. Diseases of the Anus and Fecal Fistulas. Include: Proctitis; periproc- 
titis ; proctocele ; proctoptosis ; fissure of the anus ; abscess of the margin 
of the anus; fistula of the anus, either fecal or rectovaginal. — Do not in- 
clude: Urinary fistulae, even when these involve the rectum (124) ; artifi- 
cial anus (108) (morbidity statistics alone) ; unnatural anus (108) ; im- 
perforate anus (150). (For morbidity statistics alone.) 

1 See observation under No. 40 as to " organic lesion of the stomach." 



358 POST-MORTEM EXAMINATIONS 

no. Icterus, Grave. Include: Pernicious icterus; acute yellow atrophy of the 
liver; parenchymatous hepatitis; Weil's disease. — Do not include: Icterus 
(without qualification) (114); chronic icterus; icterus of the new-born 
(I5i). 

in. Hydatid Tumors of the Liver. Include: Hydatid cyst; hydatids; echi- 
nococci. 

112. Cirrhosis of the Liver. Include: Cirrhosis (without qualification) ; alco- 

holic cirrhosis ; interstitial cirrhosis ; biliary cirrhosis ; amyloid or fatty 
degeneration of the liver ; slow atrophy of the liver ; steatosis of the liver ; 
alcoholic, interstitial, or chronic hepatitis. — Do not include: Organic lesion 
of the liver (114); hypertrophy of the liver (114). — Frequent complica- 
tions: Dropsy; hemorrhage; pneumonia; tuberculosis. 

113. Biliary Calculi. Include: Hepatic calculi; biliary lithiasis ; hepatic colic. 

114. Other Affections of the Liver. Include: Abscess of the liver; hepatitis; 

hepatitis, acute ; angiocholitis ; cholecystitis ; hepatocystitis ; choluria. To 
be also included when their precise nature is not indicated : Organic lesion 
of the liver ; tumor of the liver ; hypertrophy of the liver ; acholia ; cho- 
laemia; icterus; chronic icterus; jaundice; hepatic congestion. — Do not 
include: Grave icterus (no) ; icterus of the new-born (151). 

115. Affections of the Spleen. Include: Splenitis; splenopathia ; megalosple- 

nia; splenocele. — Do not include: The affections of the spleen due to 
leukaemia or malaria. 

116. Peritonitis, Simple (Puerperal excepted). 1 Include: Peritonitis (without 

qualification); peritonitis, chronic; peritoneal adhesions; epiploitis ; metro- 
peritonitis, pelviperitonitis. — Do not include: Tuberculous peritonitis (29) ; 
cancer of the peritoneum (41) ; puerperal peritonitis (137) ; rheumatic 
peritonitis (47). 

117. Other Affections of the Digestive Apparatus (Cancer and Tubercle ex- 

cepted). Include: Diseases of the pancreas (cancer excepted). 

118. Appendicitis and Phlegmon of the Iliac Fossa. Include: Iliac phlegmon 

or abscess; typhlitis; perityphlitis; typhlodicliditis ; appendicitis. — Do not 
include: Pelvic abscess (130) ; periuterine abscess (130) ; pelvic suppura- 
tion (130). 

VI. DISEASES OF THE GENITO-URINARY APPARATUS AND 

ITS ADNEXA. 

119. Nephritis, Acute. Do not include: Scarlatinous nephritis (7) ; chronic 

nephritis (120) ; tuberculous nephritis (33) ; nephritis of pregnancy (138). 

120. Bright' s Disease. Include: Chronic, albuminous, interstitial, or parenchy- 

matous nephritis ; albuminuria ; amyloid or fatty degeneration of the kid- 
ney; amyloid kidney; steatosis of the kidney; renal sclerosis. To be in- 
cluded when their precise nature is not indicated: Uraemia; uraemic 
eclampsia; ursemic delirium; ursemic coma. — Do not include: Organic 
lesion of the kidney (121) ; puerperal uraemia (138) ; cardiac albuminuria 
(79). — Frequent complications: Anasarca; dropsy; convulsions; hemor- 
rhages ; cerebral apoplexy ; pneumonia. 

1 When an adult female is returned as having been stricken with " peritonitis," without other ex- 
planation, the report should be returned in order that the physician may specify whether or not the condi- 
tion was puerperal. 



USUAL CAUSES OF DEATH 359 

121. Other Diseases of the Kidneys and their Adnexa. Include: Pyelitis; 

anuria ; renal congestion ; renal ectopia ; nephroptosis ; floating, motile, or 
displaced kidney; movable kidney ; renal cysts ; polycystic kidney ; hydro- 
nephrosis ; hematuria ; perinephritis ; perinephric abscess ; pyelone- 
phritis ; nephropyosis. To be also included when their nature is not speci- 
fied : Organic lesion of the kidney ; nephrorrhagia. 

122. Calculi of the Urinary Tract. Include: Renal, ureteral, nephritic, vesical, 

or urinary calculus ; nephritic colics ; nephrolithiasis ; gravel ; stone ; cal- 
culary affections ; urinary lithiasis ; lithotrity ; lithoclasty. — Do not in- 
clude: Prostatic calculus (125). 

123. Diseases of the Bladder. Include: Cystitis, acute or chronic; vesical or 

ureteral catarrh ; cystorrhagia ; tumor of the bladder ; cystocele ; cystop- 
tosis ; foreign body in the bladder ; section ; cystotomy ; retention of 
urine ; dysuria ; paralysis of the bladder ; vesical inertia ; incontinence of 
' urine; tenesmus of the bladder. — Do not include: Hematuria (121) ; uri- 
nary fistulae, even when they involve the bladder (124) ; cystosarcoma (45). 

124. Diseases of the Urethra. Include: Urinary abscess, etc.; ankylurethria ; 

foreign bodies; urethrotomy; urinary fistula (urethral, urethrorectal, vesi- 
corectal, or vesicometrorectal) ; urinary infiltration ; urinary intoxication ; 

urethralgia ; urethrorrhagia ; urinaemia ; stricture of the urethra ; urethro- 
stenosis; urethroplasty; urethrorrhaphy. — Do not include: Urethral catarrh 

(123) ; retention of urine (123). 

125. Diseases of the Prostate. Include: Hypertrophy of the prostate; prosta- 

titis; abscess of the prostate; prostatic calculus. — Do not include: Cancer 
of the prostate (45) ; tubercle of the prostate (33). 

126. NON-VENEREAL DISEASES OF THE GENITAL ORGANS OF THE MALE. Include: 

Phimosis ; paraphimosis ; amputation of the penis ; seminal losses ; sper- 
matorrhoea ; orchitis ; epididymitis ; funiculitis ; hydrocele ; hematocele 
of the testicle, cord, or scrotum; castration (in man) ; Malassez's disease. 
— Do not include: Cancer of the testicle (45) ; tubercle of the testicle 
(33) ; sarcohydrocele (45) ; syphilitic sarcocele (36) ; varicocele (83). 

127. Metritis. Include: Ulcer of the uterus; ulceration of the neck (of the 

womb). 

128. Uterine Hemorrhage, Non-puerperal. Include: Metrorrhagia; monorrha- 

gia; tamponage of the vagina or uterus. 

129. Uterine Tumor (not cancerous). Include: Fibroid tumor, or fibroid body 

of the uterus ; hysteromyoma ; uterine polypus ; fungus or fungoid tumors 
of the uterus. 

130. Other Diseases of the Uterus. Include: Ulcerations of the neck ; uterine 

or vaginal catarrh; deviation, anteflexion, retroflexion, anteversion, falling 
or prolapse of the uterus; prolapse of the vagina; uterine prolongation; 
amenorrhcea; hypertrophy of the neck of the uterus; dysmenorrhoea ; 
organic lesion of the uterus ; hysterectomy ; hysterotomy ; metrotomy ; 
ablation of the uterus; abscess of the pelvis; periuterine or retro-uterine 
abscess or phlegmon ; pelvic suppuration ; Huguier's disease ; leucorrhcea ; 
fluor albus (whites; vaginal flow; white flux). — Do not include: Puerperal 
diseases; abscess of the iliac fossa (95). 

131. Cysts and other Tumors of the Ovary. Include: Ovariotomy; castration 

(in the female). 



360 POST-MORTEM EXAMINATIONS 

132. Other Diseases of the Genital Organs of the Female. Include: Vaginis- 

mus ; tumors of the vagina ; ovaritis ; salpingitis ; salpinx ; metrosalpin- 
gitis ; hematosalpinx ; pyosalpinx ; abscess and tumors of the vulvovaginal 
glands; vulvitis; periuterine or retro-uterine hematocele. — Do not include: 
Urinary fistulse (124); stercoral fistule (109a); even when they involve 
the genital organs. 

133. Non-puerperal Diseases of the Breast (Cancer excepted). Include: Mam- 

mitis; abscess of the breast (non-puerperal); cyst of the breast; cystic 
diseases of Reclus ; tumor of the breast (without qualification, or non- 
cancerous) ; amputation of the breast. — Do not include: Fistula of the 
breast (puerperal, or without qualification) (43). 



VII. THE PUERPERAL STATE. 

Remarks. — It often happens that physicians neglect to note the puerperal char- 
acter of the disease ; hence the following rule for the guidance of those whose duty 
it is to collect statistics. " Whenever an adult female is noted as having been af- 
fected with a disease which may be puerperal, the report should be returned to the 
reporter, in order that he may state explicitly whether or not the disease was puer- 
peral." The following are these diseases : Peritonitis ; pelviperitonitis ; metroperi- 
tonitis ; septicaemia ; hemorrhage ; metrorrhagia ; eclampsia ; phlegmasia alba dolens ; 
phlebitis ; lymphangeitis ; embolism ; sudden death ; abscess of the breast. 

134. Accidents of Pregnancy. Include: Miscarriage (death of mother) ; abor- 

tion (death of mother) ; hemorrhage of pregnancy; incoercible vomiting; 
rupture of tubal pregnancy; ablation of the pregnant tube; difficulties and 
fatigues supervening in the course of pregnancy. 
134a. Labor, Normal. (Morbidity statistics only.) 

135. Puerperal Hemorrhage. Include: Metrorrhagia, puerperal. 

136. Other Accidents of Labor. Include: Dystocia; Cesarean section; rupture 

of the uterus ; metrorrhexia ; laceration or rupture of the perineum ; peri- 
neorrhaphy; placenta previa; malposition, retention, detachment, or apo- 
plexy of the placenta; cephalotripsy ; embryotomy (adult); symphyseot- 
omy; version; application of forceps; uterine inversion. 

137. Puerperal Septicemia. Include: Puerperal fever; puerperal infection; puer- 

peral endometritis ; puerperal salpingitis ; perimetrosalpingitis, or phlegmon 
of the broad ligament, or diffuse pelvic puerperal cellulitis ; puerperal peri- 
tonitis, metroperitonitis, phlebitis, lymphangeitis, or pyohemia. — Do not in- 
clude: Septicemia (without qualification) (20). 

138. Albuminuria and Puerperal Eclampsia. Include: Puerperal uremia; ne- 

phritis of pregnancy ; eclampsia of women in labor ; epileptiform convul- 
sions of women in labor ; puerperal tetanus. 

139. Phlegmasia Alba Dolens, Puerperal. Do not include: Phlegmasia alba 

dolens, non-puerperal (82). — Frequent complications: Gangrene; embolism. 

140. Other Puerperal Accidents; Sudden Death. Include: Puerperal embo- 

lism ; puerperal thrombus ; sudden death in the puerperium ; consequence 
of labor (without other explanation). — Do not include: Sudden death, non- 
puerperal (178) ; puerperal scarlatina (7). 

141. Puerperal Diseases of the Breast. Include: Fissure of the nipple (puer- 

peral) ; circumscribed abscess; abscess of the breast (puerperal); fistula 
of the breast (puerperal or without further indication). 



USUAL CAUSES OF DEATH 



VIII. DISEASES OF THE SKIN AND CELLULAR TISSUE. 



361 



142. Gangrene. Include: Eschar; sphacelus; gangrene, dry; gangrene, senile; 

gangrene of the extremities ; gangrene of the mouth ; gangrene of the 
vulva, etc.; noma; Raynaud's disease. — Do not include: Gangrene of the 
lung (96); hernial gangrene (108); gangrenous erysipelas (144). 

143. Furuncle (Carbuncle). 1 Do not include: Biskra, Aleppo, or Medina button. 

144. Phlegmon; Warm Abscess. Include: Abscess (without qualification); 

phlegmonous tumor ; adenophlegmon; suppurative adenitis ; bubo (with- 
out qualification) ; suppurating bubo ; diffuse phlegmon ; phlegmonous or 
gangrenous erysipelas ; panaris ; whitlow ; abscess of the mediastinum ; 
vomica (without any other indication). — Do not include: Bacillary abscess 
(33) ', abscess of the fauces, throat, or retropharynx (101) ; of the liver 
(114) ; of the iliac fossa (118) ; of the pelvis (130) ; of the prostate 
(125) ; urinary (124) ; periuterine (14) ; of the breast, non-puerperal (130) ; 
cold (31) ; by congestion (31) ; ossifluent (31) ; angioleucitis (84). 

145. Tinea Favus. (Morbidity statistics alone.) 

145a. Tinea Tonsurans, Trichophyton. Include: Tinea (without qualification). 
(Morbidity statistics alone.) 

145b. Pelades. (Morbidity statistics alone.) 

145c. Itch. (Morbidity statistics alone.) 

I45d. Other Diseases of the Skin and its Adnexa. Include: Erythema; urti- 
caria ; prurigo, pityriasis ; lichen ; psoriasis ; dermatitis ; eczema ; im- 
petigo ; aphtha ; herpes ; ecthyma ; elephantiasis Arabum ; pachyderma- 
titis ; polysarcia ; scleroderma ; cheloids ; fungoid mycosis ; seborrhcea ; 
trophoneuroses ; zona ; Wardrop's disease ; Biskra, Aleppo, or Medina 
button ; ' Pendine ulcer ; Cochin-China ulcer ; pemphigus ; myiasis. — Do 
not include: Pachydermatous cachexia (89) ; elephantiasis Grsecorum (17). 



IX. DISEASES OF THE ORGANS OF LOCOMOTION. 

146. Affections of the Bones (Non-tuberculous). Include: Periostitis; perios- 

tosis ; osteitis ; osteoperiostitis ; osteomyelitis ; caries ; necrosis ; seques- 
trum; perforation of the palatine vault; necrosis of the maxilla (non- 
phosphoric or without qualification) ; exostosis (without qualification) ; 
osteoma ; osseous tumor ; cranial tumor ; foreign bodies in the frontal or 
other sinuses; mastoiditis; abscess of the frontal or maxillary sinus; 
osteomalacia; softening of bone ; rhachitis; scoliosis; lordosis; kyphosis. — 
Do not include: Caries of the petrous bone (76) ; dental caries (100) ; 
osteocopic pains (36c) ; osteosarcoma (45) ; phosphorus necrosis (58). 

147. Arthritis and other Diseases of the Joints (Tuberculosis and Rheumatism 

excepted). Include: Arthritis; polyarthritis (non-vertebral); hydrarthro- 
sis; foreign bodies in joints; arthrodynia; arthropyosis ; arthrophytis ; 
ankylosis; arthralgia; arthrocele; genu valgum. — Do not include: Rheu- 
matic arthritis (47). 

148. Amputation. Include: Only those cases in which the lesion, the cause for 

amputation, is not specified. — Do not include: Amputation of the breast 

1 The word " anthrax" will be taken in the sense in which it is ordinarily employed in each country, 
as for example : in French-speaking countries, as " an aggregation of furuncles" (143) ; and as " malignant 
pustule" (22) in Russia. 



362 POST-MORTEM EXAMINATIONS 

(133) ; amputation of the penis (126). — Frequent complications: Septi- 
caemia ; erysipelas ; tetanus ; hemorrhage. 

149. Other Affections of the Organs of Locomotion. Include: Hygroma; peri- 

chondritis; disarticulation; tarsalgia; painful talipes valgus; retraction 
of the fingers or of the palmar aponeurosis; Dupuytren's disease; non- 
traumatic muscular rupture ; muscular diastasis ; myodiastasis ; non-trau- 
matic rupture of a tendon ; diseases of tendons ; tenophytes ; tenosynovitis ; 
tenotomy; tenorrhaphy; torticollis; lumbago; curvature. 

X. MALFORMATIONS. 

150. Malformations (Stillbirths not included). Include: Malformation; mon- 

strosity ; anomaly ; arrest of development ; congenital hydrocephalus ; hydro- 
cephalus (without qualification); megalocephalus ; hydrorachia; spina 
bifida ; encephalocele ; podencephalia ; congenital eventration ; omphalo- 
cele ; exomphalos ; ectopia ; imperforate anus, etc. ; hare-lip ; cleft palate ; 
anaspadias ; hypospadias ; cryptorchid ; vascular nsevus ; polydactylia ; syn- 
dactylia ; congenital club-foot ; talipes valgus, varus, or equinus, congenital ; 
congenital deafness or blindness ; persistence of the foramen of Botallo 
(foramen ovale). — Do not include: Coloboma (75); painful flat-foot 
(149) ; acquired hydrocephalus (74b). 

XL EARLY INFANCY. 

150a. The New-born and Nurslings departing from Hospitals without having 
been Sick. (Morbidity statistics alone.) 

151. Congenital Debility, Icterus, and Sclerema. 1 Include: Premature birth; 

atrophy (infantile) ; icterus or hepatitis of the new-born; atelectasis of the 
lungs in the new-born; cedema of the new-born. 

152. Other Diseases of Early Infancy. Include: Umbilical hemorrhage; in- 

flammation of the umbilicus; cyanosis of the new-born. (This title has 
reference to children not more than three months old.) 

153. Lack of Care. 

XII. OLD AGE. 

154. Senile Debility. Include: Senility; old age; cachexia (of the old); senile 

exhaustion; senile dementia. — Do not include: Senile gangrene (142). 

XIII. AFFECTIONS PRODUCED BY EXTERNAL CAUSES. 

Among suicides there should only be classed those in whom suicide or attempted 
suicide is clearly demonstrated. In collective suicides there should only be counted 
those who have attained their majority. Minors ought to be regarded as the victims 
of assassination. 

155. Suicide by Poison. Include: Voluntary poisoning; voluntary absorption of 

sulphuric acid (or any other corrosive substance). 

156. Suicide by Asphyxia. Include: Suicide by the vapor of charcoal. 

157. Suicide by Hanging or Strangulation. Include: Hanging. 

158. Suicide by Drowning. 

159. Suicide by Firearms. 

160. Suicide by Cutting Instruments. 



USUAL CAUSES OF DEATH 363 

161. Suicide by Jumping from High Places. 

162. Suicide by Crushing. 

163. Other Suicides. 

164. Fractures. Include: Separation of the epiphyses; fracture of the cranium. 

165. Sprains. Include: Strains; stretching of ligaments. (Morbidity statistics 

alone.) 
165a. Luxations. Include: Subluxations. 

166. Other Accidental Traumatisms. Include: Stabs; contusion; bites (non- 

venomous, non-virulent) ; crushing; railroad accidents (suicide excepted) ; 
wounds by cutting instruments (suicide not demonstrated) ; accidental 
falls ; concussion of the brain ; perforation of the cranium ; traumatic 
hemorrhage ; traumatic fever ; traumatic eventration ; perforation of the 
abdomen or chest ; all acute affections designated as " traumatic ;" wounds 
by firearms. 

167. Burns and Scalds. Include: Burns and scalds; burns from steam; from 

petroleum. — Do not include: Conflagration. 

168. Burns from Corrosive Substances. Include: Burns by vitriol. 

169. Insolation. Include: Sunstroke. 

170. Freezing. Do not include: Effects of cold (new-born) (153). 

171. Electrical Disturbances. Include: Death from lightning. 

172. Accidental Submersion. Include: Drowning (non-suicidal). 

173. Prostration. Include: Fatigue. (Morbidity statistics alone.) 

173a. Inanition. Include: Hunger; insufficient food (new-born excepted); mis- 
ery. — Do not include: Lack of care (new-born) (153) ; lack of nutrition 
(new-born) (153) ; sitiophobia (68) ; hysterical anorexia (74a). 

174. Absorption of Deleterious Gases (Suicide excepted). Include: Asphyxia, 

accidental (pathological asphyxia and suicidal asphyxia excepted) ; as- 
phyxia by illuminating gas; asphyxia by stoves (fixed or portable); 
absorption of carbonic oxid ; conflagration ; absorption of ammonium sul- 
phid ; asphyxia by night-soil ; absorption of chloroform ; absorption of 
nitrous oxid. — Do not include: Asphyxia of the adult (without qualifica- 
tion) (179). 

175. Other Acute Poisonings. Include: Every acute poisoning (suicide ex- 

cepted) ; antimony cholera; acute ergotism; absorption of venom; bite 
of serpent; accidental absorption of sulphuric acid or other corrosive sub- 
stances. — Do not include: Saturnism (57) ; hydrargyrism, etc. (58 or 
59) ; morphinism, chronic ergotism, etc. (59). 

176. Other External Violence. Include: Accident (without other qualifica- 

tion) ; bad treatment (upon a child) ; capital punishment ; foreign body in 
the larynx ; foreign body in the trachea. 



XIV. ILL-DEFINED DISEASES. 

The following titles will include only those conditions ill-defined by the phy- 
sician, whether from lack of sufficient data, or because the disease was ill-defined, or 
because the physician was negligent in making a complete diagnosis. 
177. Dropsy. Include: Anasarca; ascites; oedema of the extremities or gener- 
alized oedema; organic lesion (not defined). — Do not include: (Edema of 
the new-born (151) ; oedema of the glottis (88) ; oedema of the lungs 
(95) ; oedema of the brain (64). 



364 



POST-MORTEM EXAMINATIONS 



178. Sudden Death. Include: Syncope (followed by death). — Do not include: 

Puerperal sudden death (140), nor sudden death followed by an explana- 
tion, as "diabetic" (30) or "apoplectic" (64). 

179. Ill-defined or Unspecified Causes of Death. Include: Exhaustion or 

cachexia or debility (of adults); asthenia; adynamia; ataxo-adynamia ; 
coma; asthenic, hectic, colliquative, synochal, gastric, bilious, or pituital 
fever; gastric involvement; fever of detention; paralysis of the heart (in 
German " herzlahmung" or " herzschlag," in English "heart failure"); 
cyanotic asphyxia (without indicated cause, the new-born excepted) ; or 
any other insufficient diagnosis. — Do not include: Exhaustion, cachexia or 
debility of the old (154) ; fever, ataxo-adynamic, continued, summer, or 
hay (99) ; asphyxia by external cause (156 or 174) ; cyanosis of the new- 
born (152). 

An endeavor is now being made to adopt the following death cer- 
tificate throughout America. 



RETURN OF A DEATH 



IN THE CITY OF PHILADELPHIA 



Physician's Certificate. 



1 . Full Name of Deceased, 

f Cninese, 

*• Color, Stateif |fiS se ' 



= 3- Sex, 



( Widow, 

4. Single, Married State if {SS: 

Years, 

5. Age, J Months, 



«■££?: 



Days, 

(If age is less than one day, give hours. 




f Chief, 



No Certificate will be accepted 
which is MUTILATED, ILLEGI- 
BLE, INACCURATE, or any por- 
tion of which has been ERASED, 
INTERLINED, CORRECTED, or 
ALTERED, as all such changes im- 
pair its value as a Public Record. 



£ 7. Cause of Death, 



( Contributing, 



4®= This Certificate must not 
be issued for any other purpose 
than as a report to the Board of 
Health. Should the Physician 
issue a duplicate, it must be 
distinctly marked " Duplicate," 
andstate why issued. 



Residence, 



M.D. 



INDEX 

¥¥ 

(The Roman numeral letters refer to chapters ; the Arabic numeral figures to pages.) 



Abdominal cavity, diseases of organs of, 
vi, xi, xii, xiii, xiv, xxii, xxvii, 
xxviii, xxix 
exposure of, vi 

removal of organs of, xi, xix, xx 
superficial examination of organs 
of, vi 
Abortion, criminal, 314 
Abscess of brain, 183 
liver, 162 
lung, 97 
perinephric, 149 
subdiaphragmatic, 144 
Acarus scabiei, 239 
Acromegaly, 183 
Actinomycosis, 209 
Addison's disease, 130 
Adrenalin, 129 
Adrenals, diseases of, 129 
examination of, 129 
measurements of, 276 
removal of, 129 
situation of, 124 
weight of, 276 
Air-embolism, 99 
Air-passages, upper, examination of, 93, 

193 
Amyloid kidneys, 145 

liver, 157 
Anaemia cerebri, 184 
of brain, 184 
lungs, 99 
progressive pernicious, 79 
Anatomical wart, 44, 237 
Anchylostomum duodenale, 240 
Aneurisms, 90, 184 
Angular method of removing skullcap, 

166 
Anomalies of brain, congenital, 186 

cord, congenital, 186 
Anopheles, 241 



Anthracosis, 108 

Anthrax, 210 

Aorta, 144 

Apoplexia neonatorum, 184 

Apoplexy, cerebral, 187 

of lungs, 102 
Appendicitis, 120 
Arachnoid, 169 

Arteries, morbid changes in, 88 
Arteriosclerosis, 88 
Asthma, 97 
Ataxia, hereditary, 185 

locomotor, 185 
Atelectasis, 97 
Atrophy, acute yellow, of liver, 157 

progressive spinal muscular, 190 
Autopsy, see Postmortem 

B 

Bacteriological investigations, xxiv 

Basedow's disease, 102 

Beriberi, 211 

Bertillon classification, 348 

Bile ducts, 136, 138 

Biologic blood-test, 323 

Bladder, diseases of, xiii 

Blood-diseases, 79 

Blood, lesions of, viii 

Blood-stains, 322 

Blood-tests, 323 

Blood-vessels, lesions of, viii 

Bodies, examination of exterior of, v 

frozen, 207 

identification of, 308 

pecuniary value of, 4 

preservation of, 206 

removal of portions of, 5 

restoration of, 203 

right to dispose by will of, 4 
Bothriocephalus latus, 239 
Bowel, inflammation of large, 124 
Brain, abscess of, 183 

365 



3 66 



INDEX 



Brain, anaemia of, 184 
diseases of, xvii 
examination of, xv 

Dejerine's method, 173 
Giacomini's method, 178 
Hamilton's method, 176 
Meynert's method, 173 
Pitres's method, 175 
Virchow's method, 172 
hyperemia of, 188 
preservation of, Kaiserling's method, 

178 
removal of, 169 

in child, 198 
syphilis of, 227 
tuberculosis of, 232 
weight of, 271 
Bronchiectasis, 98 
Bronchitis, 98 
Brown atrophy of heart, j6 
induration of lungs, 99 
Brunetti's chisels, 32 

Bucket method of opening intestines, 116 
Burials, premature, 315 
Burns,. 320 



Caisson disease, 185 
Calcicosis, 108 
Calculi, renal, 150 

vesical, 152 
Calvarium, clamps for holding, 34 

removal of, 166 
Capsule of kidney, removal of, 128 
Cephalic cavity, inspection of, xv 
Chantemasse, bacillus of, 122 
Charcot-Leyden crystals, 97 
Chisels, 31 

Chloroform narcosis, 144, 331 
Chlorosis, 80 

Cholecystitis, acute infectious, 158 
Cholelithiasis, 159 
Cholera Asiatica, 211 
Chorea, acute, 186 
Cimex, 238 
Circular method of removing skullcap, 

165 
Circulatory system, syphilis of, 227 

tuberculosis of, 233 
Cirrhosis of liver, 159 
Clamps for holding calvarium, 34 



Clothing, care of, 309 

Cceliac plexus, 130 

Cold, death from, 319 

Colitis, 124 

Colon, dilatation of, 125 

Color of parts, 16 

Common bile duct, 138 

Comparative postmortems, xxvi 

Complications of diseases causing death, 

xxix 
Congenital defects of kidneys, 145 
Congestion of kidneys, 145 
liver, 161 

passive, of lungs, 100 
Considerations, general, i 
Cord, diseases of, xvii 

examination of, xvi 

removal of, xvi 

syphilis of, 227 

tuberculosis of, 232 
Cornell head-rest, 34, 164 
Coronary arteries, 70 
Coroner's cases, 5 

office, establishment of, 305 
Corpus delicti, 309 
Cretinism, 186 
Cryoscopy, 324 

Culture media, inoculating, 265 
Curschmann's spirals, 97 
Cystic disease of kidneys, 146 
Cysticercus cellulosse, 239 
Cystitis, 151 
Cytology, 325 



Death, ascertainment of the cause of, 2 

no cause found for, 2 

signs of, 315 

usual causes of, 316, xxix 

violent, 317 
Decomposition, post-mortem, 48, 317 
Delirium, acute, 186 
Dengue, 212 
Diabetes insipidus, 83 

mellitus, 83 
Diabetic blood, reaction for, 324 
Diaphragm, 144 

Diarrhoea, summer, cause of, 122 
Differentiation, optical, 247 
Diphtheria, 212 
Diseases, nomenclature of, 348 



INDEX 



367 



Diseases of adrenals, 129 

aorta, 144 

arachnoid, 169 

bile ducts, 136 

bladder, xiii 

brain, xvii 

common bile ducts, 138 

cord, xvii 

coronary arteries, 70 

diaphragm, 144 

duodenum, 138 * 

dura, 168 

ears, xviii 

eyes, xviii 

Fallopian tubes, 153 

gall-bladder, 136 

gall-ducts, 157, xiv 

heart, viii 

intestines, xi 

kidneys, 145 

larynx, 95, 228, 234 

liver, 157 

lungs, x 

meninges, 189 

mesentery, 121 

nasal cavities, xviii 

new-born, xix 

oesophagus, 140 

omentum, 112 

orbits, 194 

ovary, 154 

oviducts, 153 

pancreas, 142 

pericardium, 67 

peritoneum, 112 

pharynx, 95 

portal vein, 136 

prostate, 134 

psoas muscle, 144 

retroperitoneal glands, 144 

semilunar ganglia, 130 

spermatic vessels, 134 

spinal canal and cord, xvi 

spleen, 114 

stomach, 140 

testicles, 156 

ureter, 130 

urethra, 134 

uterus, 154 

vagina, 156 
Dissecting wounds, iv 



Disseminated sclerosis, 191 
Distomiasis, 240 
Dourine, 243 
Duke's disease, 219 
Duodenum, 138 
Dura mater, 168 
Drowning, 320 
Dysentery, 122 

acute catarrhal, 122 

amoebic, 123 

chronic, 123 

complications of, 123 

gangrenous, 123 



Ears, examination of, xviii 
Echinococcus disease, 241 
Electricity, death by, 318 
Embalmed bodies, 206 
Embolism, air, 99 

fat, 99 
Embryos, length of, at different ages, 

280 
Emphysema of liver, 161 

lungs, 100 
Encephalitis, 186 
Encephalon, examination of, xv 
Endarteritis obliterans, 89 
Endocarditis, 87 

Engines, dental and trephining, 28 
Enterotome, 29 
Epiglottis, examination of, 95 
Erysipelas, 214 
Expert testimony, 306 
Exterior of body, examination of, v 
Extra-uterine pregnancy, 153 
Exudate, 59 
Eyes, examination of, xviii 

F 

Face, examination of, xx 
Fallopian tubes, diseases of, xiii 
Fat embolism, 99 
Fatty changes in liver, 161 
Fever, glandular, 214 

paratyphoid, 119 

typhoid, 118 
Filaria sanguinis hominis, 240 
Fixatives, 246, 256 
Foot-and-mouth disease, 214 
Formad pocket-case, 38 



3 68 



INDEX 



Frambcesia, 215 
Friedreich's ataxia, 185 
Fright, 144 
Frozen bodies, 206 



Gall-bladder, 136 

Gall-ducts, diseases of, xiv 

Gall-stones, 159 

Gangrene of lungs, 101 

Gastritis, 141 

Gastro-intestinal tract, syphilis of, 227 

General considerations, i 

Genitalia, female, removal of, 132 

male, removal of, 134 
Genito-urinary system, tuberculosis of, 233 
German measles, 222 
Glanders, 214 
Goitre, 101 

exophthalmic, 102 
Gonorrhceal infection, 216 
Gout, 84 

Graduated cones, 35 
Graves's disease, 102 



Hsematomyelia, 187 

Hsematozoa, diseases due to, xxii 

Haemophilia, 81 

Haemoptysis, causes of, 99 

Hammers, 31 

Hands, care of, iv 

Hanging, 320 

Hardening, 255 

Harke's method, 193 

Hay fever, 97 

Heart, actinomycosis of, 88 

amyloid degeneration of, 89 

anomalies of, 76 

characteristics of, 76 

degeneration of, 86 

dilatation of, 85 

dimensions of, 273 

diseases of, viii 

examination of, 69 

hypertrophy of, 85 

infiltration of, 86 

lesions of, viii 

removal of, 71 

syphilis of, 88 

tuberculosis of, 88 



Heart, tumors of, 88 

valvular diseases of, 88 

volume of, 274 

weight of, 273 
Heat, death from, 319 
Height, 267 

Hemiplegia in children, 187 
Hemorrhages, 85 

cerebral, 187 

into spinal membranes, 188 

of lungs, 102 

pulmonary, 102 
Hepatitis, suppurative, 162 
Hereditary ataxia, 185 
Hey's saw, 26 
Hide-bound skin, 224 
Hydronephrosis, 146 
Hydrophobia, 216 
Hydrostatic lung test, 345 
Hyperemia, cerebral, 188 



Identification of the body, 308 
Illumination, 12 
Infanticide, 320 
Infants, autopsies on, 312 
Infarcts of kidney, 146 

lungs, 99, 102 
Influenza, 217 
Injection, preservative, 207 
Instruments, proper and improper, iii 

to be taken to postmortem, 2>^> 

use of, iii, 24 
Insular sclerosis, 191 
International system of nomenclature of 

diseases and causes of death, 348 
Interstitial nephritis, 147 
Intestines, diseases of, 116 

gall-stones in, 120 

hemorrhage of, 120 

removal of, 115 

worms in, 120 
Intra-uterine gestation, period of, 313 



Kaiserling method, 261 

Kidneys, 125 

amyloid changes in, 145 
congenital defects of, 145 
congestion of, 145 
cystic disease of, 146 



INDEX 



369 



Kidneys, diseases of, xii 

examination of, 128 

hydronephrosis of, 146 

infarcts of, 146 

movable, 148 

opening of, 127 

parasites of, 148 

removal of, 126 

stones of, 150 

syphilis of, 227 

tuberculosis of, 233 

tumors of, 150 

weights and measures of, 275 
Knife, method of holding, 38 
Knives, 24 

Koch controversy, 282 
Kromskopic pictures, 2 



Large bowel, 125 
•Laryngitis, cedematous, 102 
Larynx, removal of, 95 

syphilis of, 228 

tuberculosis of, 234 
Leontiasis ossea, 184 
Leprosy, 218 
Leptomeningitis, acute, cerebrospinal, 

chronic diffuse, 189 

deep chronic, 189 
Leucocythaemia, 80 
Leukaemia, 80 
Light, artificial, 7 
Lithosis, 108 
Liver, 136 

abscess of, 162 

acute yellow atrophy of, 157 

amoebic abscess of, 123 

amyloid degeneration of, 157 

cancer of, 158 

cirrhosis of, 159 

congestion of, 161 

dimensions of, 275 

disease of, xiv 

emphysema of, 161 

fatty changes in, 161 

sarcoma of, 162 

syphilis of, 228 

tumors of, besides cancer and 
coma, 163 

volume of, 275 

weight of, 274 



188 



Lividity, post-mortem, 48 
Longitudinal sinus, 168 
Luer's rhachiotome, 27 
Lungs, abscesses of, 97 

air-embolism of, 99 

anaemia of, 99 

apoplexy of, 102 

atelectasis of, 97 

brown induration of, 99 

circulatory disturbances of, 99 

dimensions of, 274 

diseases of, x 

emphysema of, 100 

examination of, ix 

fat embolism of, 99 

gangrene of, 101 

hemorrhage of, 102 

infarcts of, 99, 102 

oedema of, 99 

passive congestion of, 100 

removal of, 93 

syphilis of, 109, 228 

tuberculosis of, 109, 234 

tumors of, no 

volume of, 274 

weight of, 274 
Lupus vulgaris, 237 
Lymphatic glands, tuberculosis of, 235 
Lymph-glands, retroperitoneal, 144 

M 

Malaria, 241 

Mai de caderas, 243 

Malta fever, 219 

Mammary gland, tuberculosis of, 236 

Measles, 219 

German, 222 
Measures, xxv 
Medicolegal postmortems, 311, xxviii 

suggestions, xxvii 
Meningitis, acute cerebrospinal, 189 
Meningo-encephalitis, 189 
Mesentery, disease of, 121 
Micromegaly, 184 

Micro-organisms, diseases due to, xxii 
Miliary tuberculosis of the lungs, no 
Morbilli, 219 
Movable kidney, 148 
Miiller's fluid, 250 
Mumps, 220 
Muscular atrophy, progressive spinal, 190 



24 



37° 



INDEX 



Myelitis, acute, 190 

from compression, 190 
Myelotome, 25 
Myiasis, 240 
Myocarditis, 86 

N 
Nagana, 243 
Narcosis, 144, 331 
Nasal cavity, examination of, 201 
Nasopharynx, examination of, xviii 
Necropsy, see Postmortem 
Nematodes, 240 
Nephritis, interstitial, 147 
parenchymatous, 148 
New-born, examination of, xix 
Noma, 109 

Nomenclature of causes of death, xxix 
Notes, taking of, 1, 2, 14 



Obligations of physicians to their patients, 
305 

Odor of parts, 17 

(Edema of lungs, 99 

(Esophagus, 140 

examination of, 95 

Omentum, 112 

Oral cavity, examination of, 201 

Orbits, examination of, 194 

Organs, characteristics of, 14 

Osmic acid, 253 

Osteitis deformans, 184 

Osteo-arthropathy, hypertrophic pulmon- 
ary, 184 

Ovaries, diseases of, xiii 

weight and measures of, 278 

Oviducts, 134, 153 

Oxyurus vermicularis, 240 



Pancreas, 142 

weight and measures of, 277 
Pancreatitis, 143 
Parasites, 148, 238 

diseases due to, xxii 
Paratyphoid fever, 119 
Parenchymatous nephritis, 148 
Pediculi, 238 
Pelvic organs, 132 
Penetration, 247 
Pericarditis, 68 



Pericardium, 67 
Perinephric abscess, 149 
Peristalsis, reversed, 119 
Peritoneum, 112 
cancer of, 112 
tuberculosis of, 236 
Peritonitis, 112 
Permission to perform postmortem, 4 

method of obtaining, 4 
Pharynx, 95 
Phthisis, no 

Pia mater, removal of, 169 
Pick's myelotome, 25 

Placenta, weight of, at different ages, 268 
Plague, 220 
Pleurae, diseases of, x 
examination of, ix 
Pleurisy, 102 
Pneumonia, 104 
catarrhal, 107 

and croupous, differences be- 
tween, 107 
chronic interstitial, 104 
croupous and catarrhal, differences 
between, 107 

complications of, 105 

lesions of, 105 

terminations of, 105 
lobar, 105 
Pneumonoconiosis, 108 
Pneumothorax, 108 
Poison, definition of, 326 
Poisoning by acids, 328 

aconite, 329 

alcohol, 329 

alkalies and caustic salts, 330 

antimony, 330 

arsenic, 330 

atropine, 331 

carbon monoxid, 332 

chloral hydrate, 331 

cocaine, 331 

copper, 331 

cyanide of potassium, 332 

ergot, 331 

formaldehyd, 332 

hydrocyanic acid, 332 

illuminating gas, 332 

lead, 333 

mercury, 333 

methyl alcohol, 333 



INDEX 



371 



Poisoning by nitrobenzol, 333 

opium, 333 

pellagra, 334 

phosphorus, 334 

potassium chlorate, 334 

ptomain, 335 

silver nitrate, 335 

snakes, 335 

strychnine, 335 

suspected, 311 

toadstool, 335 
Poisons, classification of, 328 
Poliomyelitis, acute anterior, 191 
Portal vein, 136 

Postmortems, additions to account of, 2 
cleanliness at, 8 
comparative, xxvi 
definition of, 1 
general considerations of, 1 
in hospital, 8 

morgues, 8 

private house, 8 
instruments for, 36 
interval to elapse before performance 

of, 6 
legal right to perform, 3 
made before dressing, 7 

by artificial light, 7 
medicolegal, 311 
on anatomical cases, 5 
operations at, 3 
order of examination, 18 
permission for, 4 

method of obtaining, 4 
place of making, 7 
preparation for, 8 

Prussian regulations for the perform- 
ance of medicolegal, 336 
purpose of, 1 

record books, forms for, 20, 22 
restricted, xx 
room, furnishings of, 9 
study anatomy at, 3 
synonyms of, 1 
time of making, 6 
treatment of wounds at, 40 
Post-mortem decomposition, 48 
instruments, i 
lividity, 48 
note-taking, i 
records, i, 14 



Post-mortem rigidity, 48 

table, 8 

wounds, iv 
Potassium bichromate, 249 
Preservation of bodies, xxi 

tissues, xxiii 
Prostate, 134 

weight and measures of, 279 
Prussian regulations, 336 
Psilosis, 225 
Psoas muscles, 144 
Psorospermiasis, 242 
Pulex, 238 
Purpura, 82 
Pyelitis, 149 
Pyelonephritis, 149 

K, 

Rabic tubercle, 217 

Radio-activity of dead bodies, 313 

Raspatory, 32 

Raynaud's disease, 191 

Records of postmortems, 14 

Rectal enema, reversed peristalsis after, 

119 
Rectum, 115, 132 
Regulations, Prussian, 336 
Relapsing fever, 221 
Restoration of body, xxi 
Retroperitoneal lymph-glands, 144 
Reversed peristalsis, 119 
Rhachiotome, 27 
Rheumatic fever, 222 
Rheumatism, chronic, 222 
Rigidity, post-mortem, 148 
Rigor mortis, ante-natal, 312 
Rotheln, 222 
Rubber gloves, 35 
Rubella, 222 
Rubeola, 219 

S 

Salpingitis, 154 

Sarcoma of the liver, 162 

Sarcoptes scabiei, 239 

Satterthwaite's calvarium clamp, 33 

Saws, 26 

Scalds, 320 

Scalp, 164 

Scarlet fever, 222 

Scissors, 29 



37 2 



INDEX 



Scleroderma, 224 
Sclerosis, disseminated, 191 

insular, 191 
Scurvy, 82 

infantile, 83 
Semilunar ganglia, 130 
Serous membranes, tuberculosis of, 236 
Serum blood-test, 323 
Shiga, bacillus of, 122 
Siderosis, 108 
Silicosis, 108 

Skin, tuberculosis of, 237 
Skull and brain, examination of, xv 

examination of, 165 

shape of, 270 

thickness of, 166 

types of, 270 
Smallpox, 224 
Smear preparations, 263 
Spermatic vessels, 134 
Spinal canal and cord, xvi 
Spine, 225 
Spleen, diseases of, 114 

removal of, 113 

weight and measures of, 277 
Starvation, death by, 320 
Statistics, morbidity and mortuary, 348 
Stegomyia, 238 
Stomach, 140 

contents of, 139 

hemorrhage of, 142 

removal of, in cases of poisoning, 139 
Stomatitis, 108 
Stones of kidney, 150 
Strangulation, 320 
Suffocation, 320 
Suggestions, medicolegal, xxvii 
Suprarenals, see Adrenals 
Surra, 243 
Syphilis, 225' 
Syringomyelia, 191 



Tabes dorsalis, 185 
Taenia flavopunctata, 239 

saginata, 239 

solium, 239 
Testes, syphilis of, 229 

weight and measures of, 278 
Testicles, diseases of, xiii 
Tetanus, 229 



Thoracic cavity, examination of, vii. 64 
inspection of, 65 
duct, 144 

Thrush, 229 

Thymus gland, weight and measures of, 
277 

Thyroid gland, arsenic in, 331 
examination of, 95 
weight and measures of, 278 

Tissues, preservation of, 244 

Tongue, removal of, 95 

Tonsils, removal of, 95 

Toxicology, 325 

Trachea, examination of, 95 

Transudate, 59 

Trichina spiralis, 240 

Trichosis vesicae, 151 

Trypanosoma, 243 

Tuberculosis, 229 

Tuberculous ulcers, 118 

Typhoid fever, 237 
ulcers, 118 



Ulcers of intestine, typhoid, 118 

tuberculous, 118 
Uncinariasis, 240 
Ureters, 130 

situation of, 125 

tying of, in operations, 130 
Urethra, 134 
Urine, collection of, 132 
Use of post-mortem instruments, : 
Uterus, diseases of, xiii 

opening of, 133 

weight and measures of, 279 



Vagina, diseases of, xiii 

Valentine knife, 25 

Vena cava, 144 

Vesical calculi, 152 

Viability, determination of, 312 

W 

Wart, anatomical, 44, 237 

Weights, xxv 

Wounds, treatment of post-mortem, 40 



Yellow fever, 238 



JUN 5 1903 



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